Tanner Spring Memory Care

Abbreviations possibly used in this document: ADL: activities of daily livingCBG: capillary blood glucose or blood sugarCG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

The findings of the on-site investigation, conducted 10/20/25, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

The findings of the on-site investigation, conducted 10/20/25, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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 01/22/25 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas:

* Large standing mixer – metal guard dusty/food debris and base of mixer behind guard had food drips/spills;

* Wall behind standing mixer – drips/spills;

* Wall below counter of dirty dish washing area side – drips/spills of brown matter;

* Wall and caulking behind the spray hose in dish washing area – build up of black matter;

* Side of stove – drips/spills ;

* Ceiling vents and surrounding ceiling above dish washing area – build up of dust; and

* Wall behind cooking equipment – drips/spills of grease.

Other areas of concern include:

* Walk in freezer – undated/unlabeled food items (portioned cheesecake and hashbrowns) and two boxes stored on floor.

* Male staff not wearing beard restraints.

The areas of concern were observed and discussed with Staff 1 (Dining Service Manager) and discussed with Staff 2 (Executive Director) on 01/22/25. 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 07/22/24 through 07/25/2024, 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. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit to the re-licensure survey of 07/25/24, conducted 11/12/24 through 11/13/24, are documented in this report. The survey was conducted to determine compliance with 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 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 re-visit to the re-licensure survey of 07/25/24, conducted on 02/06/25, 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 and interview, it was determined the facility failed to ensure the residents' rights to be treated with dignity and respect and to receive services in a manner that protects privacy and dignity. Findings include, but are not limited to:During an interview on 07/24/24 with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) it was revealed that multiple shared rooms lacked a barrier between the two sides of the room to protect privacy and dignity during ADL care. Observations during the survey revealed that all resident bathroom doors were not lockable for resident privacy. The need to ensure residents' rights of privacy and dignity were upheld was discussed with Staff 1 and Staff 2 on 07/25/24. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia and delusional disorder.The resident's current service plan, dated 07/10/24, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, did not provide clear instruction to staff, and/or was not implemented in the following areas: * Toileting assistance, including frequency and clear direction on delivery of services;* Fall interventions for shower safety; and* Interventions related to behaviors.The need to ensure service plans were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 07/25/24. They acknowledged the findings.
2. Resident 4 was admitted to the facility in 03/2023 with diagnoses including dementia. The resident was hospitalized on 07/09/24 through 07/11/24 and returned with diagnoses including acute renal failure, congestive heart failure and with hospice services.Observations with the resident, interviews with staff, review of the resident's service plan dated 06/10/24, hospice visit notes, and progress notes, dated 04/03/24 through 07/22/24, were completed. The resident's service plan was not reflective, lacked resident-specific direction for staff and/or was not implemented in the following areas:* Indwelling catheter care instructions;* Bed bound;* Two person assist for bed mobility, dressing, incontinence care, and evacuation;* Bathing;* Oxygen use with instructions;* Meal assistance;* Fluid intake instructions;* Personal hygiene;* Location of pain, to include non-pharmacological interventions; * Hospice services and instructions for when/how to contact;* Apartment room kept locked;* Elopement risk;* Skin conditions and interventions; and* Updated activities plan after significant change of condition. 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 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 07/24/24. They acknowledged the findings.
4. Resident 3 moved into the MCC in 04/2022 with diagnoses including chronic myeloproliferative disease.Observations of the resident, interviews with staff, and review of the most recent service plan, dated 06/22/24, and temporary service plans showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and was not being implemented in the following areas: * Level of assistance required for eating;* Use of high back reclining wheelchair; * Use of side rails; * Frequency of routine incontinence care;* Schedule of hospice services;* Current wound status and treatment;* RN to perform weekly skin assessments of wound and treatment;* Padded heel protectors to be worn during the day; and* Geri-sleeves to be worn on upper and lower extremities during the day.The need to ensure resident service plans reflected current care needs, provided clear direction to staff, and was implemented was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 07/25/24. 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' current care needs and preferences, provided clear direction regarding the delivery of services, or was implemented 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 2 was admitted to the facility in 11/2022 with diagnoses including dementia and cognitive communication deficit.The resident's current service plan, dated 06/10/24, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, did not provide clear instruction to staff, and/or was not implemented in the following areas: * How resident expressed pain and/or discomfort;* Non-pharmaceutical interventions regarding pain and anxiety; * Facility nurse to perform weekly skin assessment and wound treatment;* Wound monitoring, including ensuring wound was covered and unsoiled; * Use of an air pressure mattress for pressure ulcer;* Toileting assistance, including number of staff, clear direction on delivery of services, and assistive devices used;* Evening care needs, including toileting;* Sleep schedule including times assisted in and out of bed;* Use of a hospital bed; and* Environmental factors, including noise level, tolerance and preference.The need to ensure service plans were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) and on 07/25/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 03/2023 with diagnoses including dementia. Resident 4's service plan, dated 06/10/24, and progress notes, dated 04/03/24 through 07/22/24 were reviewed. Observations were made and care staff were interviewed during the survey.The following changes of condition lacked documentation of resident-specific actions or interventions needed for the resident and/or progress noted at least weekly through resolution:* 06/07/24, bruise to the back of the left wrist approximately three inches long; and * 07/12/24, the resident returned to facility after hospitalization with new diagnoses including acute rental failure, congestive heart failure, had an indwelling catheter, decline in ADLs and hospice services implemented.The need to ensure resident-specific actions or interventions for changes of condition were determined and progress noted at least weekly through resolution was discussed with Staff 1 (Memory Care Director), and Staff 2 (Resident Care Coordinator) on 07/24/24. Staff acknowledged the findings and no additional information was provided.
Based on observations, interview, and record review, it was determined the facility failed to determine resident-specific actions or interventions needed for residents following a short-term change of condition, communicate the determined actions or interventions to staff, and document progress until the condition resolved for 2 of 4 sampled residents (#s 3 and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2022 with diagnoses including chronic myeloproliferative disease.Observations of Resident 3, interviews with staff, and review of the resident's 06/22/24 service plan, temporary service plans, and 04/03/24 through 07/19/24 progress notes were reviewed. Resident 3's progress notes identified the following: * 04/28/24: Fall with skin tear to left ankle;* 05/24/24: Staff noted Resident 3 needed assistance with eating "resident benefits greatly from assistance with feeding" and ate their entire meal; * 06/06/24: Staff noted "wound is looking worse than yesterday and seems [his/her] leg is also starting to swell and become more reddish pink;" and* 06/06/24: Staff noted a new injury "wound to top of head scabbed over and healing."The above short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, or documented weekly progress until the condition resolved.On 07/25/24 the need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Memory Care Director), and Staff 2 (Resident Care Coordinator) on 07/25/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan for 1 of 1 sampled resident (#6) who experienced a significant change of condition. The resident experienced ongoing, severe weight loss. This is a repeat citation. Findings include, but are not limited to:Resident 6 moved into the facility in 03/2021 with diagnoses including dementia and was identified during the acuity interview as having experienced a significant weight loss.The resident's 11/08/24 service plan, temporary service plans and progress notes from 09/23/24 to 11/12/24, and weight records from 09/2024 to 11/08/24 were reviewed. Observations of the resident were made, and interviews with staff and the resident were conducted.The following weights were documented in the resident record:09/03/24- 159 pounds;10/03/24- 150.4 pounds;11/03/24- 148.7 pounds;11/08/24- 143.6 pounds; and11/12/24- 143.8 pounds (taken during survey).Between 09/03/24 to 10/03/24 the resident lost 8.6 pounds, or five percent of his/her bodyweight, constituting a severe weight loss. Resident 6 continued to lose weight and experienced a 15.2-pound weight loss between 09/03/24 and 11/12/24, or 9.5% of his/her bodyweight, constituting a severe weight loss. The weight loss constituted a significant change of condition for which the facility was required to evaluate, refer to the facility nurse, document the change, and update the service plan. Review of the resident's record revealed no documented evidence the weight loss was evaluated, the facility nurse was notified, the change was documented, and the service plan was updated, and there were no documented interventions for the weight loss.During an interview at 10:55 am on 11/12/24, Staff 2 (Resident Care Coordinator) confirmed there was no documented evidence the weight loss was referred to the facility nurse. The nurse was no longer employed at the facility and not available for interview. Staff 2 further confirmed Resident 6's weight loss had not been evaluated or documented, and the service plan had not been updated.The resident was observed eating lunch on 11/12/24 and 11/13/24. S/he was independent with eating and was able to verbalize his/her choice of meal offerings. S/he was observed to consume approximately 50% of the food and liquid offered during both meal observations, including a taco, soup, mashed potatoes, apple juice, and water. Resident 6 experienced a severe weight loss in one month without an evaluation, referral to the facility nurse, documentation of the change, or a service plan update. S/he continued to lose weight, resulting in a severe weight loss in three months. On 11/13/24 at 12:45 pm, the need to ensure resident significant changes of condition were evaluated, referred to the facility nurse, documented, and the service plan was updated was discussed with Staff 1 (Memory Care Director) and Staff 2. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 2 and 4) who experienced significant changes of condition, and failed to have a licensed nurse who was regularly scheduled for onsite duties at the facility, and assure adequate number of nursing hours relevant to the census and acuity of the resident population. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 03/2023 with diagnoses including dementia and chronic kidney disease.Review of the resident's service plan, dated 06/10/24, temporary service plans and progress notes, physician and hospital communications and hospice visit notes dated 04/03/24 through 07/22/24 was completed.Resident 4 was hospitalized for chest pain, shortness of breath, and elevated blood pressure from 07/09/24 to 07/11/24. The resident returned with new diagnosis of acute renal failure, congestive heart failure, and an indwelling catheter and was on hospice services prior to return.Multiple observations of the resident between 07/22/24 and 07/24/24 showed the resident in bed, asleep most of the time, requiring two person assistance with bed mobility, incontinent cares and dressing, and full assistance with all other ADL activities. The resident was refusing or unable to take food and fluids, with staff observed using a water moistened swab for oral care and to provide fluids. Care staff interviewed reported that prior to hospitalization the resident was independent with bed mobility, toileting, ambulation with a walker, ate independently in the dining room, needed set up and cueing assistance with ADLs and shower assistance from staff. The resident experienced a significant change related to an overall decline, hospice services, and placement of an indwelling catheter. The facility failed to ensure an RN assessment was completed related to the resident's decline, catheter and admission to hospice services which documented findings, resident status, and interventions made as a result of the assessment.The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 07/24/24. The staff acknowledged the findings.2. During an interview with Staff 1 (Memory Care Director), she stated the facility's RN worked primarily in the ALF, coming to the memory care facility when needed or called. She stated the RN did not have regularly scheduled hours for onsite duties in the memory care facility.The need to ensure the facility had a licensed nurse who was regularly scheduled for onsite duties at the facility, and assured adequate number of nursing hours relevant to the census and acuity of the resident population was discussed with Staff 1 (Memory Care Director) on 07/24/24. She acknowledged the findings.
3. Resident 2 was admitted to the facility in 11/2022 with diagnoses including dementia and cognitive communication deficit. Resident 2's clinical records were reviewed. On 03/05/24 an outside provider visit note identified the resident had developed a stage II pressure ulcer to the right lateral heel.There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, and developed interventions related to the resident's significant change of condition. On 07/25/24 at 11:01 am, Staff 1 (Memory Care Director) stated there was no documented evidence of an RN assessment for Resident 2. This surveyor requested to interview the facility RN on 07/22/24, 07/23/24, and 07/24/24 and the facility RN was not available to interview. The need to ensure an RN assessment was completed for all residents with a significant change of condition was discussed with Staff 1 and Staff 2 (Resident Care Coordinator) on 07/25/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to address all evaluated care needs of residents, including the amount of staff time needed to provide care in the facility's acuity-based staffing tool (ABST) for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose ABST input was reviewed. Findings include, but are not limited to:The facility's ABST was reviewed and discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 07/23/24.A review of Residents 1, 2, 3 and 4's ABST input revealed multiple care areas were not reflective as to the number of minutes the residents' evaluated care needs required. Therefore, the ABST staffing plan did not accurately reflect the number of care hours required for each shift.The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff minutes needed to provide care, was discussed with Staff 1 and Staff 2 on 07/24/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted with all required elements documented and failed to provide fire and life safety training to staff on alternate months per the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire and life safety records, reviewed between 02/2024 and 07/2024, revealed the following:a. The facility failed to relocate or evacuate residents during fire drills; therefore, documentation was lacking in the following areas: * Problems encountered, comments relating to residents who resisted or failed to participate in the drills;* Evacuation time-period needed; and* The number of occupants evacuated.b. There was no documented evidence fire and life safety instruction was provided to staff on alternating months from fire drills.The need to ensure fire drills and fire and life safety training was provided and documented as required was reviewed with Staff 1 (Memory Care Director) and Staff 5 (Maintenance Coordinator) on 07/25/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to re-instruct residents 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 07/23/24 the facility fire and life safety records were reviewed. The facility lacked documented evidence residents who were capable were re-instructed at least annually on general safety procedures, evacuation methods, and responsibilities. On 07/24/24 at 9:15 am, Staff 5 (Maintenance Coordinator) reported that currently there was not a system in place for re-instructing residents annually on fire and life safety procedures.The need to develop a system for re-instructing residents at least annually on fire safety procedures was discussed with Staff 1 (Memory Care Director) and Staff 5 on 07/25/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C270.

Based on observation and interview, it was determined the facility failed to ensure residents rights of privacy and dignity. Findings include, but are not limited to:Refer to C200.

Based on observation and interview, it was determined the facility failed to ensure residents rights of privacy in his or her own unit. Findings include, but are not limited to:Refer to C200.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 200, C 361, C 372, C 420, and C 422.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 12, 13 and 14) completed all required pre-service orientation, 2 of 3 new staff (#s 12 and 14) demonstrated competency in all job duties within 30 days of hire, and 2 of 3 long-term staff (#s 6 and 15) completed the required number of hours of annual in-service training. Findings include, but are not limited to:Staff training records were reviewed on 07/23/24 through 07/24/24.a. There was no documented evidence Staff 12 (MT), Staff 13 (CG) or Staff 14 (CG), hired 04/26/24 and 05/08/24, respectively, completed the following pre-service orientation topics prior to beginning their job duties:* Resident rights and values of CBC care;* Abuse reporting requirements;* Fire safety and emergency procedures; and* Written job description.b. There was no documented evidence Staff 12 or Staff 14 demonstrated competency in one or more assigned duties within 30 days of hire:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Identification, documentation, and reporting changes of condition;* Conditions which require assessment, treatment, observation, and reporting;* General food safety, serving, and sanitation; and* Other duties as applicable (e.g., med pass, treatments).c. There was no documented evidence Staff 6 (CG), hired 07/18/22, or Staff 15 (MT), hired 04/22/20 completed 16 hours of annual in-service training, with 10 hours being related to the provision of care in Community Based Care and six hours related to dementia care, or infectious disease training. The need to ensure all staff training was completed in the required time frames was discussed with Staff 1 (Memory Care Director) an 07/24/24. She acknowledged the findings. Staff 12 completed documented MT training on 07/24/24 with Staff 2 (Resident Care Coordinator).

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

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 C270.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and documented in the resident's service plan for 2 of 3 residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to:Resident's 2 and 3's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 07/25/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to:Resident service plans and activity evaluations were reviewed. There was no documented evidence the facility had fully evaluated and developed individualized plans based on the residents':* Current abilities and skills;* Emotional and social needs and patterns;* Physical abilities and limitations;* Adaptations necessary for the resident to participate; and* Identification of activities for behavioral interventions, if necessary.On 07/24/24 at 1:20 pm, the failure to ensure residents had individualized activity plans developed based on their activity evaluations, was discussed with Staff 4 (Life Enrichment Director) and Staff 1 (Memory Care Director). They acknowledged the findings.

The findings of the kitchen inspection, conducted 12/12/23, 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 12/12/23, conducted 01/24/24, 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 12/12/23 at 10:50 am, the following concerns were observed in the facility kitchen:* The hood vents above the stove and grill area had a build-up of grease and dust;* The ceiling vents throughout the kitchen had dust build-up, including the ceiling area surrounding those vents;* The wall area near the ceiling between prep area and the stove/grill area had a build-up of dust; and* Four staff were not wearing hair and/or beard restraints.The areas of concern were observed and discussed with Staff 1 (Dining Manager) and discussed with Staff 2 (Memory Care Director) on 12/12/23. 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.

The findings of the on-site investigation, conducted 11/13/23 through 11/14/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. 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 interview and record review, conducted during a site visit 11/13/23 through 11/14/23, it was confirmed the facility failed to implement the resident's right to receive services in a manner that protects privacy and dignity for 1 of 1 sampled resident (#6). Findings include, but are not limited to:A photo provided by Adult Protective Services was reviewed. Staff 8 (CG) can be seen in the facility with Resident 6 in the background. Resident 6's face was visible in the photo and a caption read, "When its St Patrick's Day but you're stuck at work instead of partying." The photo was posted to social media.During a phone interview on 11/10/23, Witness 1 (former facility staff) stated s/he saw the picture on social media.During interview on 11/14/23, Staff 6 (Administrator) stated she was aware of the photo being posted to social media and had immediately spoken with the Staff 8 about it.The findings were reviewed with and acknowledged by Staff 6 on 11/14/23.It was confirmed the facility failed to implement the resident's right to receive services in a manner that protects privacy and dignity.Verbal plan of correction: Administrator discussed with staff in question and will review HIPAA at shift change meetings within one week.

Based on interview and record review, conducted during a site visit from 11/13/23 through 11/13/23, it was confirmed the facility failed to implement written policies and procedures on medical emergency response for all shifts for 1 of 1 sampled resident (#5). Findings include, but are not limited to:A review of Resident 5's progress notes dated 01/01/23 through 01/14/23 revealed:*On 01/08/23 Resident 5 had an unwitnessed fall with injury. Progress notes did not indicate that facility nurse or Resident 5's family were notified, or note any attempts to notify.*On 01/09/23 Resident 5 had another unwitnessed fall with injury. Facility RN, ED and family were notified. *Resident 5 passed away on 01/14/23. A review of the facility's minor/major injuries policy and procedure indicated:"All minor emergencies/injuries shall be reported to the family and/or responsible person as soon as possible... notification of family and/or responsible person will be documented in the progress notes in the Resident's file."During an interview on 11/14/23, Staff 6 (Administrator) stated Resident 5's family and the facility nurse should have been notified of Resident 5's 01/08/23 fall immediately, but were not. The findings were reviewed with and acknowledged by Staff 6 on 11/14/23.The facility failed to implement written policies and procedures on medical emergency response for all shifts.Verbal plan of correction: MT meeting to review incident reports and minor/major injuries policy and procedure was conducted at 2 pm on 11/14/23.

Based on interview and record review, conducted during a site visit 11/13/23 through 11/14/23, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to:The facility had an active ABST Condition: RCDCD23- 00369, with the following staffing standards imposed:Day: 3 CGs, 2 MTsSwing: 2 CGs, 1 MTNoc: 2 CGs, 1 MTA review of time cards for 10/29/23 - 11/4/23 revealed day shift on 10/31/23, 11/2/23 and 11/04/23 were staffed short of the imposed staffing requirements.In an interview on 11/14/23, Staff 6 (Administrator) stated the facility had several call-outs that week and agreed they were short of the imposed staffing standards.The findings were reviewed with Staff 6 on 11/14/23.The facility failed to fully implement an ABST.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 01/30/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on observation and interview, it was confirmed that the facility failed to ensure that each residential care and assisted living facility is licensed, maintained, and operated as a separate and distinct facility. Findings include but not limited to:During an unannounced site visit on 1/30/2023, Compliance Specialist (CS) observed Staff #1 (S1) receive a phone call from an Assisted Living Facility (ALF) staff member requesting assistance with a fall that occurred in the ALF. S1 left the memory care unit to assist in the ALF, leaving only Staff #2 (S2) on the floor in the memory care.During interview, S1 stated that the ALF needed assistance with the fall. They also stated that in December 2022, they worked as a medication technician in the ALF and the memory care during the same shift.These findings were reviewed with S4 and S6 on 1/30/2023.Plan of Correction: Facility to review and audit the ABST for accuracy. They will provide education to staff on separate facilities and in-service on proper channels for communication in the event of an emergency.

Based on observation, record review and interview, it was confirmed that the facility failed to employ a full-time administrator scheduled to be on-site in the facility at least 40 hours per week. Findings include but not limited to:During an unannounced site visit on 1/30/2023, Compliance Specialist observed Staff #4 (S4) onsite who was acting as administrator.A review of the Oregon Health Licensing Office records revealed that S4 is not a licensed administrator.During interview, Staff #1- #2 (S1-S2), Staff #4 (S4) and Staff #6 (S6) stated:*S4 is the new administrator.*S6 was the administrator for both the memory care and the ALF*S4 is working on getting their license.*S4 has support from ALF ED and corporate Administrator.*Their regional director currently holds the administrator license for the building, but they are not here full time.These findings were reviewed with S4 and S6 on 1/30/2023.Plan of Correction: S4 is in training and has completed most of the necessary coursework. They will be scheduling their test as soon as possible for licensing. Current Administrator in training has support from ALF ED as well as corporate administrator.

Based on observation, interview and record review, it was confirmed that the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to:During an unannounced site visit on 1/30/2023, Compliance Specialist (CS) observed Staff #1- Staff #2 (S1-S2) working in the memory care unit for the noc shift. At around 0510 S1 was called by an Assisted Living Facility (ALF) staff member to help with a fall that occurred. S1 left to assist ALF staff, leaving only S2 on the memory care unit.During interview, S1, S2 and Staff #3 (S3) stated:*There are eight residents that require two person assist for transfers.*They would be unable to evacuate the building in the event of a fire or emergency.*There was an occasion in December 2022 when there was only one Medication Technician (MT) for the whole building and that MT worked both the ALF and the Memory Care on the same shift.*Family members get their food handler cards to help feed residents.*There are five residents who require 1:1 assistance with eating.*It is common on Sundays for there to only be two caregivers (CGs) and one medication technician (MT) on swing shift.A review of the facility's posted staffing plan revealed the need for:Day: three CG and two MTsSwing: three CG and one MTNoc: one CG and one MTThese findings were reviewed with Staff #4 and Staff #6 on 1/30/2023.Plan of Correction: Technical assistance was provided by CS on how to input data into ABST for residents who require two person assistance. Facility will audit and update their ABST with this information. Facility is implementing an on-call phone number to help with call-outs and staffing. They are actively hiring staff.

Based on observation, interview and record review, it was confirmed that the facility failed to fully implement and update an Acuity-Based Staffing Tool (ABST). Findings include but not limited to:During an unannounced site visit on 1/30/2023, Compliance Specialist observed two staff members, Staff #1- Staff #2 (S1-S2) working in the memory care unit for the noc shift. At around 0510 S1 was called by an Assisted Living Facility (ALF) staff member to help with a fall that occurred. S1 left to assist ALF staff, leaving only S2 on the memory care unit.During separate interviews, S1, S2 and Staff #3 (S3) stated:*There are eight residents that require two person assistance for transfers.*They would be unable to evacuate the building in the event of a fire or emergency.*There was an occasion in December 2022 when there was only one Medication Technician (MT) for the whole building and that MT worked both the ALF and the Memory Care on the same shift.*Family members get their food handler cards to help feed residents.*There are five residents who require 1:1 assistance with eating.*It is common on Sundays for there to only be two caregivers (CGs) and one medication technician (MT) on swing shift.A review of the facility's posted staffing plan revealed the need for:Day: three CG and two MTsSwing: three CG and one MTNoc: one CG and one MTA review of the facility's ABST revealed that that 22 of the resident's ABST profiles had not been reviewed or updated since June 2022. Resident #3 (R3)'s profile had not been updated since 10/28/2022. A review of Resident #3 (R3)'s progress notes revealed that they returned from the hospital on 1/20/2023 and newly required the use of a hoyer lift for all transfers. The need for two person assistance with the hoyer was not reflected in the ABST. A review of Resident #4 (R4)'s care plan revealed he/she required two person assistance for transfers, which was not reflected in the ABST and had not been reviewed or updated since 06/15/2022.During interview, Staff #4 and Staff #6 were unable to explain how two staff members could safely evacuate residents from the facility. They were also unable to demonstrate how the need for two people with transfers was accounted for in the ABST.These findings were reviewed with S4 and S6 on 1/30/2023.Plan of Correction: Technical assistance was provided by Compliance Specialist on how to input data into ABST for residents who require two person assistance. Facility will audit and update their ABST with this information. Facility is implementing an on-call phone number to help with call-outs and staffing. They are actively hiring staff.

The findings of the Change of Ownership survey conducted 6/1/21 through 6/9/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a daySituations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area:OAR 411-054-0025 (4) Reasonable Precautions;OAR 411-054-0030 Resident Services Meals, Food Sanitation Rule;OAR 411-054-0030 (1) e.f.g Resident Services: ADLs;OAR 411-054-0036 (1-4) Service Plan;OAR 411-054-0045 (1) a-f (F)(A)(C-F) Resident Health Services;OAR 411-054-0070 (1) Staffing Requirements;OAR 411-057-0167 2c Nutrition and hydration; andOAR 411-057-0160 Behaviors.The facility put immediate plans of correction in place during the survey and the situations were abated.
The findings of the first revisit survey for the Change of Ownership survey on 06/09/21, conducted 11/08/21 through 11/10/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar 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 2nd revisit to the re-licensure survey of 06/09/21, conducted 02/03/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 004 Home and Community Based Services Regulations and OARs 411 Division 57 for Memory Care Communities.

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location to residents and visitors, and available for inspection. Findings include, but are not limited to:A tour of the facility conducted on 6/1/21 identified the following required postings were not displayed:*The name of the administrator or designee in charge; and*A copy of the most recent re-licensure survey, including all revisits and plans of correction.On 6/1/21, the need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (Memory Care Director) and Staff 15 (Maintenance Director). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving complaints. Findings include, but are not limited to:1. A review of Family Council minutes, dated 1/2021 and 5/2021, revealed the following concerns: * Short staffed; * Services not being provided to residents according to care plans; * Care conferences were overdue, service plan meetings were delayed; * Delayed response to be screened when visiting or when needing to speak with staff; and * Not providing clear visitation guidelines.2. During the survey, multiple family members approached the survey team and expressed their concerns with the following: * Inadequate staffing levels; * Dissatisfaction with daily routine care giving; * Overdue care conferences or care plan meetings; * Serving pureed meals that were not nutritious, poor food quality/service; * Staff were not wearing their name badges while in the facility; * Inadequate activity program; * Lack of hydration provide to residents; * Lack of a forum to meet with Administration to discuss concerns/problems; and * The Administrator or facility management team seemed to ignore complaints or concerns were not resolved. 3. During the survey, the following were observed and were identified: * Insufficient number of direct caregiving staff to provide care and services; * Not providing daily routine care to the residents who required assistance including bathing, toileting, showers and meal assist as outlined; * Overdue care conferences or care plan meetings; * Delayed response or no response to be screened when visiting; * Serving inadequate nutritious balanced food quality/service, especially with pureed diets; * Staff were not wearing their name badges; * Not providing an activity program as scheduled or outlined in Memory Care Communities; and * Lack of hydration program as outlined in Memory Care Communities. These concerns were documented in Family Council minutes along with responses from the facility, however, the responses or plans were not followed up or not implemented to address the concerns. During the survey, the above concerns continued to be identified.On 6/3/21, the above findings were shared with Staff 1 (Memory Care Director). No further information was provided.Refer to C 160, C 200, C 240, C 242, C 243, C 260, C 280, C 360, Z 163 and Z 164.

Based on interview and record review, it was determined the facility failed to maintain complete and accurate records for 6 of 15 sampled residents (#s 1, 2, 5, 7, 8 and 14) whose records were reviewed. Findings include, but are not limited to:1. Resident 1's record was reviewed during the survey and found to be incomplete in the flowing areas:* An order for oxycodone, prescribed on 5/26/21 was not in the resident's record; and * "ADL Flow Sheets" and "Bowel Monitoring Logs" were missing from the resident chart.2. Resident 2's record was reviewed during the survey and found to be incomplete in the flowing areas:* An order for Tylenol 500 mg three times daily, prescribed on 3/05/21 was not in the resident's record.3. Resident 5's "ADL Flow Sheet" to track showers, and "Bowel Movement Log" had multiple blanks on the forms where staff had not signed to indicate services had been provided or residents bowel movements had been monitored;4. Resident 7's service plan was missing from the service plan binder and the resident's chart. Staff were unable to locate it prior to survey exit. 5. Resident 8's 3/2021 monthly weight had not been recorded on the residents weight log. Resident's records indicated the resident had lost a severe amount of weight between 1/2021 and 5/2021.6. Resident 14's 6/2021 weights had been recorded inaccurately, which was verified when surveyor observed weights for the resident. 7. On 6/8/21 survey requested copies of the 5/30/21 through 6/7/21 meal tracking logs. The facility could not provide logs for 5/31/21, 6/1/21, and 6/7/21. The need to ensure resident records were complete and accurate was reviewed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 6/4/21 and 6/8/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:During the survey, conducted 6/1/21 through 6/9/21, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.Refer to the deficiencies in the report.

The following additional observations were made between 6/1/21 and 6/4/21:5. On 6/2/21 at 9:03 am, staff assisted a non-sampled resident to the dining room in his/her wheelchair, placed the resident at a table, and left the area. The non-sampled resident grabbed a cup of water off the table, which had been served to another resident, and drank it. 6. On 6/2/21 at 11:50 am, Staff 4 was observed setting the dining room tables for lunch. Staff 4 touched the eating tip of the silverware, a residents blanket, and pushed a food cart through the dining room with the silverware on top of the cart. She then returned to the kitchenette and placed the leftover silverware into a drawer. Staff 4 did not wear gloves or perform hand hygiene during the observation.7. On 6/3/21 at 3:35 pm, a non-sampled resident was observed sitting in a high back wheelchair in the dining room, near the nursing station. The resident was holding a pudding cup with a plastic spoon in it. The resident appeared confused and did not know what to do with the pudding cup or spoon. The resident then bit the plastic spoon and used his/her tongue to lick the pudding out of the cup.8. On 6/3/21 at 5:05 pm, Resident 10 was observed sitting on a wheelchair in the dining room. The resident moved his/her arm, spilling a full cup of water onto the floor near another resident sitting at the table. Several ambulatory residents were walking through the dining room at the time. Staff made no attempt to clean up the spill. On 6/3/21, the above observations were shared with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator). They acknowledged the findings.9. During the survey, Staff were observed entering the facility without being screen by dedicated staff. Staff documented on the screening form "self" screened. Shared the observation with Staff 1 and Staff 2 during the survey and provided the guidance to ensure all visitors and staff are screened by dedicated staff prior to entering the facility. Ensure staff are not screening themselves.10. Refer to survey citations:C 200 Resident Rights and Protections;C 231 Abuse Reporting and Investigation;C 240 Food Sanitation Rules;C 243 Resident Services: ADLs;C 260 Service Plans;C 270 Change of Condition and Monitoring;C 280 Resident Health Services - Significant Change; C 360 Staffing Requirements;Z 164 Nutrition and Hydration Plans; and Z 165 Behaviors.
Based on observation, interview and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. This placed residents at risk and constituted an immediate threat to residents' health and safety. Findings include, but are not limited to:1. During interviews on 6/4/21, Staff 1 and Staff 3 confirmed the facility used an "IAlert" ipod system which notified staff when a resident or staff activated a call light in a resident's room. Staff further confirmed there were not enough ipod's available for all staff working the floor, so some staff had been using walkie talkies, but most of them did not work. At 4:18 pm survey requested an immediate plan of correction to address the lack of devices available to staff which would connect the residents call system to staff on the floor. Survey received the plan at 5:45 pm and the situation was abated. The need to ensure staff on all shifts had enough ipods or walkie talkies in order to communicate with other staff and respond to resident call lights was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 6/4/21. They acknowledged the findings.2. Resident 1 was admitted to the facility 1/2014 with diagnoses including Alzheimer's disease. a. On 6/2/21 at 9:30 am the resident was observed sitting in a high back wheelchair in the dining room. His/her head was tipped to the left and unsupported. At 9:55 am Staff 14 (RN) walked up to the resident and stated "Hi [resident name] let me check your toes" bent down to look the resident's toes and walked away. At 10:04 am Resident 1 appeared to try and support his/her head with his/her left hand, but the residents left elbow slipped off the arm rest of the wheelchair. At 10:31 am Staff 1 (Memory Care Director) placed a pillow behind resident 1's head. At 10:47 am care staff wheeled the resident into the common area living room, at which time the resident's head slipped off the pillow. Staff did not reposition the resident or pillow. At 11:29 am the resident was brought into the dining room. At 11:54 am Staff 7 (MT) administered crushed medication to the resident without repositioning the residents head, which was tilted to left and pushed forward from the pillow. At 12:03 pm the residents head was almost touching his/her shoulder, and his/her left arm was hanging over the left arm rest of the wheelchair. At 12:13 pm staff put a cup of water up to the residents' mouth and encouraged him/her to drink, at which point the resident began to cough. Staff then attempted to offer the resident a bite of puree food. The resident appeared to be sleeping and did not eat. Staff did not attempt to reposition the resident's head while offering food or fluids. Staff failure to reposition the resident prior to administering medication or providing food and fluids placed the resident at risk for choking and/or aspiration, threatening the health and safety of the resident. b. On 6/2/21 at 1:04 pm surveyor requested and was granted permission to observe ADL care of Resident 1. Staff 8 (Care Partner) and Staff 16 (Care partner) donned gloves, then transferred the resident into a hospital bed using a Hoyer lift. Staff 8 removed the residents slipper from his/her left leg and placed a pillow under the calf of the right leg. Staff 8 rotated the resident onto his/her right and then left side while Staff 16 removed the resident's pants and incontinent product. Staff 8 cleaned the residents bottom and perineal area with a wet wipe, then placed a new brief on the resident, and repositioned the pillow under resident's right calf. Both care staff then covered the resident with a blanket. Staff did not change gloves or perform hand hygiene during the observation. The need to ensure proper positioning of a resident for comfort and safety, and the need to ensure proper infection control and universal precautions were followed when providing care to residents was discussed with Staff 1 and Staff 2 on 6/3/21. They acknowledged the findings. 3. Resident 5 was admitted to the facility 4/2021 with diagnoses including dementia. A review of the resident's clinical records showed the resident had eloped from the facility on 5/6/21, 5/9/21 and 5/18/21. Resident's 4/29/21 move in evaluation identified the resident was an elopement risk and stated the resident had "left home many times." There was no documented evidence the facility had implemented reasonable precautions or interventions after the 5/6/21 or 5/18/21 elopements to help prevent the resident from subsequent elopements. The facilities failure to evaluate the resident and implement effective interventions to prevent elopement placed the resident at serious risk for harm. The need to ensure the facility implemented reasonable precautions to protect residents at risk for elopement was discussed with Staff 1 and Staff 2 on 6/3/21. They acknowledged the findings.4. The following observations were made between 6/1/21 and 6/4/21:a. On 6/1/21 at 11:44 am Staff 4 (Dietary Supervisor) was standing in the kitchenette resting her head on her arm on the half counter wall between the kitchenette and dining room while waiting to serve the resident's lunch. Staff 4 was also observed touching the tip of utensils, instead of the handles, while setting the dining room tables with silverware. Staff was not wearing gloves and did not perform hand hygiene prior to touching the silverware. b. On 6/2/21 at 11:54 pm an unsampled resident picked up two sanitized wash cloths provided by staff to sanitize resident's hands prior to meals, unrolled them, then rolled them back up and placed them back on the table. Staff at the table provided no redirection, then used the wash clothes to wipe two female resident's hands. c. On 6/3/21 at 5:30 pm Staff 1 and Staff 2 were requested by the survey team to tour the dining room. During the tour, the following issues were identified: * A full cup of water had spilled on the floor near a resident sitting at a table, staff had not attempted to clean the spill up, which was first observed by survey at 5:10 pm; * Food identified as "puree" had been served in Styrofoam cups and was the consistency of water;* Multiple residents were walking through the dining room barefoot, one unsampled resident was moving from chair to chair and putting his/her feet up on other dining room chairs. The bottom of the resident's feet were brown/black in color; and * A resident's shoe was sitting on one of the dining room tables. Upon completion of the walk through, Staff 1 and 2 were directed to remove the liquid puree and request new puree meals from the kitchen. (Refer to C 240, example 1)d. On 6/4/21 at 5:10 pm a surveyor informed Staff 3 (Executive Director) Resident 5 was walking up and down the hallways with a brown substance on his/her hands. Staff 3 checked on the resident, and confirmed the brown substance was bowel matter. Staff 3 put protective gloves on, removed a washcloth from a sanitizer unit, and walked down the hallway to the resident. She returned a few minutes later with the washcloth balled up in her hands (with visible bowel matter on the cloth), walked through the dining room into the administrative office and stated to Staff 2 "what should I do with this?" Staff 3 then walked out of the office, still holding the fecal covered washcloth in her hand, directly in front of the surveyor and into the laundry room. e. On 6/4/21 at 5:18 pm two unsampled residents were observed sitting on a couch near the kitchenette, one with a walker placed in front of him/her. Two plates of food were placed on the seat of the walker. Staff 3 observed the plates sitting on the walker and directed care staff to move the plates and residents to a table. Care staff responded "I thought they could pretend they were having a picnic."f. Multiple care staff were observed during meals not wearing aprons or performing hand hygiene prior to serving residents meals or assisting residents with eating. The need to ensure staff consistently used effective universal precautions was discussed with Staff 1 and Staff 2 on 6/2/21, 6/3/21 and 6/4/21. They acknowledged the findings.

7. On 6/3/21 the survey team was informed Resident 15 had been required to quarantine for a week in his/her room after s/he had been diagnosed with shingles. A 4/23/21 Temporary Service Plan indicated "Res. (Resident) quarantined x 5 days d/t (due to) shingles. Dayshift please tell housekeeping no cleaning in RM (room) ...".On 6/8/21 at 9:50 am, Staff 7 (MT) confirmed the resident had shingles on his/her back and had to stay in his/her room for approximately one week.There was no clear clinical documentation of why Resident 15 was required to isolate. Requiring the resident to stay in his/her room against their will and restricting his/her ability to associate, interact or communicate with other individuals when there was no risk to the health and safety of other residents was considered involuntary seclusion and was considered neglect.On 6/8/21, the surveyor shared the above findings and discussed unnecessary seclusion with Staff 1 (Memory care Director) who acknowledged the findings.8. Random observations on 6/1/21 between 11:50 am and 12:32 pm were made. A non-sampled resident was sitting in a wheelchair in the dining room. A Care partner re-located the resident to the next table without any explaining why she was moving the resident. Then assisted the resident with his/her lunch.The need to ensure residents were treated in a manner that promoted dignity and respect was discussed with Staff 1 (Memory Care Director), Staff 3 (Executive Director), Staff 13 (VP memory care) and Staff 17 (Chief Operating Officer) on 6/9/21 during the exit. They acknowledged the findings.9. On 6/4/21 at 4:10 pm, Resident 13 was observed, wandering in the hallway and entered another resident's room wearing an incontinent product and a T-shirt. The incontinent product was sagging and appeared to be wet. There were more than 10 residents in the hallway and common area. There was no staff present at the time of the observation. The surveyor alerted Staff 2 (Resident Care Coordinator) of the situation. Staff 2 then looked for caregiving staff instead of addressing the resident's care needs.The need to ensure residents were treated in a manner that promoted dignity and respect was discussed with Staff 1 (Memory Care Director) and Staff 2 on 6/4/21. They acknowledged the findings.
6. Observations on 4/27/21, showed a staff member yelling down the hallway "(unsampled resident name) do you have to pee!" which the resident responded "no". The staff member then proceeded to yell "Well me either!" This constituted a failure of the facility to provide services in a manner that protected privacy and dignity.On 6/9/21, the need to ensure services are provided to residents in a manner that protects privacy and dignity was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure 12 of 12 sampled residents (#s 1, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15) were protected from neglect, and failed to ensure residents received services in a manner that promoted privacy, respect and dignity in a homelike environment. Resident 1's pain was not adequately assessed or treated following an ankle fracture. Residents 6, 7, 8, 9, 10, 11, 12, 13 and 14 had significant to severe weight loss that was not evaluated or assessed, no interventions were implemented to prevent further weight loss. Resident 15 was subject to involuntary seclusion. Findings include, but are not limited to:1. Resident 1 was admitted to the facility 1/2014 with diagnoses including Alzheimer's disease. a. On 5/23/21 staff discovered swelling and bruising to the resident's right ankle and documented the resident "screamed in pain" during cares. On 5/26/21 the resident was diagnosed with two fractures in his/her right ankle and sent to the emergency department (ED) for treatment and pain management. Staff documented the following in the resident's progress notes: * 5/23/21 " ...while changing [his/her] brief resident screamed in pain.";* 5/23/21 On call provider prescribed "PRN acetaminophen 500 mg tablet take 1 tab every 6 hours for pain";* 5/24/21 "Resident still having pain when foot is moved.";* 5/25/21 "Resident does wince and cry out if [right] foot is moved."; * 5/25/21 "Right foot is extremely painful ..."; and * 5/26/21 "(Resident) moaned with pain when care staff were doing cares." The failure of the facility to adequately evaluate or treat the severity of the pain between 5/23/21 when the injury was first discovered and 5/26/21 when the resident was sent to the ED and was prescribed a narcotic pain reliever, resulted in unreasonable discomfort to the resident and constituted neglect.Refer to 270, example 1b. On 6/2/21 at 12:13 pm care staff repeatedly shook residents left arm to wake the resident up to feed him/her. At 12:22 pm staff used a clothing protector to wipe the residents face, instead of using the napkin on the table. Staff failed to provide resident services in a respectful and dignified manner. The need to ensure residents experiencing pain were evaluated, assessed and provided effective treatment, and services provided to residents were done in a way to promote dignity and respect was discussed with Staff 1 (Memory Care Director), Staff 3 (Executive Director), Staff 13 (VP Memory Care) and Staff 17 (Chief Operating Officer) on 6/9/21. They acknowledged the findings.2. Resident 5 was admitted to the facility 4/2021 with diagnoses including dementia. Observations of the resident, 6/1/21 through 6/4/21, showed the resident exhibiting the following behaviors, for which staff provided no redirection or cueing: * Pounding on exit doors;* Swearing and yelling at other residents sitting in the hallway and other common areas;* Removing items from other resident's rooms, including sunglasses and clothing items; * Repeatedly walking up to and standing in front of an unsampled female resident, pulling at the string of his/her pajama pants in an aggressive manner and clenching his/her fists; and* Walking up to staff members and other residents, placing his/her arm near their face to show them his/her tattoos. Resident 5's behaviors, and the lack of staff redirection or interventions to address the behaviors resulted in a loss of dignity to the resident and failed to ensure a homelike environment for the other residents in the facility. The need to ensure residents were treated in a manner that promoted dignity and respect in a homelike environment was discussed with Staff 1 (Memory Care Director), Staff 3 (Executive Director), Staff 13 (VP Memory Care) and Staff 17 (Chief Operating Officer) on 6/9/21. They acknowledged the findings.3. Resident 8 was admitted to the facility 2/2018 with diagnoses including dementia.On 6/3/21 at 5:00 pm resident was observed to have spilled his/her health shake on the dining room table. Staff 8 (Care Partner) picked up the residents clothing protector to wipe up the spill, smearing the health shake across the top of the table, then walked away. At 5:10 pm the resident placed his/her arm on the table and put his/her head down on his/her arm and into the smeared shake. Staff then placed the resident's dinner plate on the table, next to the residents head and on top of the spilled shake. Staff failed to provide resident services in a manner that promoted dignity and respect. At 5:30 pm staff were directed by surveyor to clean the table and resident. The need to ensure residents were treated in a manner that promoted dignity and respect was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 6/3/21. They acknowledged the findings.4. During the survey, 6/1/21 through 6/9/21, the following residents were identified with significant to severe weight loss: * Resident 8 had a three-month weight loss of 23 lbs., or 15.03 % of their total body weight;* Resident 9 had a six-month weight loss of 14 lbs., or 12.28 % of their total body weight;* Resident 10 had a six-month weight loss of 13 lbs, or 11.40 % of their total body weight;* Resident 11 had a three-month weight loss of 13 lbs., or 8.93 % of their total body weight;* Resident 12 had a six-month weight loss of 20 lbs., or 13.25 % of their total body weight;* Resident 13 had a six-month weight loss of 23 lbs., or 14.8 % of their total body weight; and* Resident 14 had a three-month weight loss of 9.8 lbs., or 8.0 % of their total body weight. Record review and interviews showed the facility failed to have an effective system for monitoring resident weights and food or fluid intake, and failed to assess, develop interventions, or monitor interventions for effectiveness when a resident was identified with a weight loss.The facilities failure to evaluate, assess or develop interventions to prevent further weight loss resulted in physical harm to the residents and constituted neglect. On 6/8/21 at 11:47 am, the survey team requested an immediate plan of correction to address each resident's weight loss, and a plan to ensure the residents would be offered food and fluid at each meal. At 6:52 pm, survey received and accepted the plan, and the situation was abated. The need to ensure the facility had an effective system for assessing residents with significant to severe weight loss, which included developing and monitoring interventions for effectiveness was discussed with Staff 1 (Memory Care Director) and Staff 13 (VP Memory Care) on 6/8/21. They acknowledged the findings. 5. Staff were observed multiple times throughout the survey treating residents in a manner that was not dignified or respectful. Observations include but were not limited to: * On 6/2/21 at 9:30 am staff escorted an unsampled resident in his/her wheelchair out of the dining area, while stating "I'm going to go change [him/her] up", in front of other staff and residents; * On 6/2/21 at 12:27 pm a care staff yelled across the dining room to Staff 2, stating "guess what [unsampled resident] did in the bathroom?" This staff then pushed her chair away from the dining table, lifted her feet up in the air with her knees bent and imitated the resident putting his/her feet up on the grab bars in the bathroom when staff where attempting to position residents wheel chair for transferring to the toilet; * On 6/2/21 an unsampled resident was observed eating a pureed meal with his/her fingers, spilling the food on his/her pants and clothing protector;* On 6/3/21 at 3:30 pm a caregiver walked up to an unsampled male resident who was sitting in a geri chair in the main common area, bent down over the resident and appeared to smell the resident's private area. The staff member then wheeled the resident down the hall to provide incontinent care. There were approximately 25 other residents in the common area at the time; * On 6/4/21 at 5:10 pm Staff 3 (Executive Director) yelled across the dining room "Who has 3 A" "[she/he] has stuff on his/her hands"; and * Multiple times during the survey, 6/1/21 through 6/9/21, staff were observed to address residents as "sweetie", "honey", or "honey bun", discussed their personal lives in front of residents while assisting with meals and without engaging residents in conversation, yelled across the room or down the hall at residents to redirect residents behaviors, or were using their phone while assisting residents to eat. The need to ensure residents were treated in a manner that promoted dignity and respect was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 6/3/21 and 6/4/21. They acknowledged the findings.

4. Resident 2 was admitted to the facility in 2017 with diagnoses including dementia with depressive mood, secondary Parkinson's disease and gait abnormality. Resident 2 required a wheelchair for mobility. Observations of the resident from 6/1/21 to 6/4/21 showed the resident required 2-person assistance with transfers and incontinent care.a. Clinical records reviewed from 2/5/21 to 5/31/21 noted the following:On 5/24/21 staff documented on a facility "Progress notes" "a bruise on [his/her] right leg and lower left abdomen."There was no documented evidence the facility conducted an immediate investigation to reasonably conclude the unknown injury was not the result of abuse.Staff 1 (Memory Care Director) confirmed she had not reported the above incidents to the local unit, at which time the surveyor requested Staff 1 to immediately self-report the incidents to the local SPD. Confirmation the report had been sent to SPD was received on 6/9/21 prior to survey exit.b. Progress notes and incident reports dated 2/5/21 through 5/31/21 indicated the following:* On 4/8/21 staff noted "the resident walking with walker to chair. When [he/she] got close to chair, [his/her] knees locked up and [staff] assisted [him/her] to floor."* On 4/11/21 staff noted "Res [resident] was being sat onto chair and res [resident] sat too soon and sat on arm of chair and slide down to floor."The resident's 3/23/21 Temporary Service Plan indicated staff were to place a chair behind the resident instead of having the resident turn around to sit down and 2-person assistance with transfer.There was no documented evidence the facility conducted an investigation to reasonably conclude the above incidents were not the result of abuse or neglect due to the possibility of not placing a chair behind of the resident and 2-person assist with transfer.The need to investigate unknown injuries and incidents of suspected abuse or neglect and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 1 and Staff 2 (Resident Care coordinator) on 6/3/21 and 6/8/21. The staff acknowledged the findings.Refer to C 270, example 4
5. Resident 4 was admitted to the facility in September 2020 with diagnoses including dementia.Review of Resident 4's record identified the following deficiencies:* On 2/13/21 and 2/15/21, the resident was involved in a resident to resident altercations and were reported to the local SPD office on 3/29/21, 42 days after the incident occurred. The facility failed to report the incidents timely to the local SPD office;* On 3/15/21, Resident 4 was involved in a resident to resident altercations and were reported to the local SPD office on 3/23/21, 13 days after the incident occurred. The facility failed to report the incident timely to the local SPD office; and* On 5/19/21, Resident 4 was involved in a resident to resident altercation. There was no documentation of the response of staff at the time of the incident or the incident being reported to the local SPD office. On 6/4/21, the surveyor reviewed the incident with Staff 1 (Memory Care Director). She acknowledged the incident represented suspected neglect, and should have been reported to the local SPD office. Confirmation the incident was reported was received on 6/4/21.On 6/4/21 and 6/8/21, the need to ensure immediate notification to the local SPD office, or the local Area Agency on Aging, of incidents of abuse or suspected abuse was discussed with Staff 1 and Staff 2 (Resident Care Coordinator). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure an injury of unknown cause and repeated incidents of being found on the floor were promptly investigated to rule out abuse/neglect and were reported to the local SPD office when unable to reasonably conclude the incidents were not abuse and/or neglect for 5 of 5 sampled resident (#s 1, 2, 4, 5 and 8). Failure to immediately and thoroughly investigate incidents of abuse or potential abuse for injuries of unknown origin placed residents at risk for further abuse and neglect. Findings include but are not limited to: 1. Resident 1 was admitted to the facility 1/2014 with diagnoses including Alzheimer's disease. Resident 1 was mostly non-verbal, relied on staff for all ADL care and was a two-person transfer with a Hoyer lift. a. On 5/23/21 staff documented the resident had bruising on his/her lower right abdomen, left arm, and swelling and bruising to the right foot. * On 5/26/21 Resident 1 was diagnosed with two fractures to the right ankle and was sent to the emergency department for casting of the right leg and pain management. * Observations of the resident, 6/1/21 through 6/4/21 showed the resident had a soft cast on his/her right foot extending to just below the right knee. * During an interview, 6/1/21 at 2:14 pm, Staff 7 (MT) stated she had not worked the day the injury was discovered (5/23/21 by night shift staff), but did work the following Tuesday (5/25/21) and noticed the residents leg was "black and blue" and "obviously" swollen. "[Resident] would scream out in pain" if anyone touched his/her leg or attempted to move the resident. After observing the resident on 5/25/21, Staff 7 ordered a mobile x-ray of the leg. * During an interview, 6/3/21, Staff 9 (Care Partner) stated she had worked the evening shift on 5/22/21, had not put the resident to bed that night, but did transfer the resident "a few times" for toileting and did not notice any injury or indication the resident was in pain. * Upon surveyor request, the facility provided fax cover sheets indicating the incident had been reported to the local SPD on 5/23/21 and 5/25/21, and a copy of the incident report which had been completed when the injuries were discovered. * There was no evidence the facility conducted an immediate and thorough investigation to rule out abuse or neglect of care or had developed follow up actions to prevent the resident from sustaining future injuries. This put the resident at risk for future abuse. * On 6/8/21 Staff 1 (Memory Care Director) and Staff 13 (VP) stated Staff 1 was still "investigating the incident". b. On 4/29/21 staff documented Resident 1 had bruises to the back of each calf. There was no evidence the facility conducted an immediate investigation to rule out abuse or potential abuse or reported the injury of unknown cause to the local SPD office. The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 6/8/21 prior to survey exit. The need to ensure injuries of unknown cause or any incidents of abuse or suspected abuse were immediately investigated or reported was discussed with Staff 1 and Staff 2 (Resident Care Coordinator) on 6/4/21 and 6/8/21. They acknowledged the findings. No further information was provided. 2. Resident 5 was admitted to the facility 4/2021 with diagnoses including dementia. a. A review of the resident's clinical records showed the resident had eloped from the facility on 5/6/21, 5/9/21 and 5/18/21.A review of the facility investigations, including incident reports, progress notes, and SPD self-reports showed the following deficiencies:* On 5/6/21 staff failed to document individuals present; response of staff at the time of the event, follow up action or administrator review. The incident was not reported to SPD until 5/26/21, 20 days after the incident occurred; * On 5/9/21 staff failed to document the accurate time, date, place and individuals present, a complete description of the event, and indicated abuse had been ruled out without documentation of a thorough investigation; and * On 5/18/21 staff failed to document time, date, place and individuals present, a complete description of the event, or staffs response at the time of the elopement. b. On 5/24/21 staff documented resident had a scrape on the top of his/her right foot. A temporary service plan dated the same day indicated staff had "cleaned" and "bandaged" the foot. There was no evidence the facility conducted an immediate investigation to rule out abuse or reported to the local SPD if abuse could not be ruled out. The facility was directed to self-report the incident to the local SPD. Confirmation the report had been sent to SPD was received on 6/8/21, prior to survey exit. c. On 5/29/21 staff witnessed Resident 5 push another resident "up against the entry doors and walk away." There was no evidence the facility had conducted a thorough investigation which included any follow up action or administrator review. The incident was not reported to the local SPD until 6/1/21. The need to ensure injuries of unknown cause or any incidents of abuse or suspected abuse were immediately investigated or reported was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 6/4/21 and 6/8/21. They acknowledged the findings. No further information was provided.3. Resident 8 was admitted to the facility 2/2018 with diagnoses including dementia.On 5/19/21 staff documented "small [skin tear] inside labia. [Resident] is needing better peri care." There was no evidence the facility had investigated the incident or reported the injury of unknown cause to the local SPD.On 6/8/21 Staff 1 confirmed the incident had not been investigated or reported. The facility was directed to self-report the incident to the local SPD office. Confirmation the incident had been reported was received on 6/8/21, prior to survey exit.The need to ensure injuries of unknown cause or any incidents of abuse or suspected abuse were immediately investigated or reported if necessary was discussed with Staff 1 and Staff 2 (Resident Care Coordinator). No further information was provided.


Based on interview and record review, it was determined the facility failed to conduct an immediate investigation to rule out possible abuse or suspected abuse or to report to the local Seniors and People with Disabilities (SPD) office for 3 of 3 sampled residents (#s 14, 16 and 17) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 17 was admitted to the facility in April 2021 with diagnoses including dementia.Review of Resident 17's clinical records during the survey revealed the following:* 10/20/21 - Resident 17 was observed by staff to have a bruise of unknown origin on the top of his/her right hand. An incident report was completed but did not contain information ruling out abuse. There was no documented evidence the facility had conducted an immediate investigation to reasonably conclude the above situation was not the result of abuse. The facility did not report the incident to the local SPD office.During a discussion on 01/09/21 at 9:15 am, Staff 20 (Interim MCC Administrator) and Staff 22 (RCC) confirmed it had not been investigated nor reported to the local SPD office. The surveyor requested Staff 20 report the incident to local SPD office. On 11/10/21, the above findings were shared with Staff 20 and Staff 22. Confirmation the report had been sent to local APD office was provided to the surveyors.
2. Resident 14 was admitted to facility 04/2021 with a diagnosis including dementia. Review of Resident 14's records noted an unwitnessed fall on 10/26/21. Resident 14 was also noted to have a cracked tooth on 11/03/21. The facility investigations did not document how they had ruled out abuse and neglect. The need to thoroughly investigate all incidents to rule out suspected abuse and/or neglect was discussed with Staff 20 (Interim MCC Administrator on 11/10/21. She acknowledged the findings.
3. Resident 16 was admitted to the memory care in April 2021 with diagnoses including dementia.A review of Resident 16's 10/09/21 through 11/08/21 progress notes, incident reports and interim service plans revealed the resident had experienced an unwitnessed fall resulting in an injury on 10/18/21. Staff documented finding the resident at 8:15 pm in his/her room on the floor leaning against the inside of the room door. The resident was sent to the emergency department and diagnosed with a head laceration requiring staples for closure, and two lumbar compression fractures. The resident returned to the facility on 10/19/21.Although the facility did report the incident to the local SPD office, the facility failed to promptly investigate the incident and/or document the following:* Individuals present at the time of the incident;* A full description of the event; and* Follow-up action. There was no evidence the Administrator had reviewed the incident prior to 11/01/21. The need to ensure all incidents of abuse or suspected abuse or neglect were thoroughly invested and reviewed by the Administrator was discussed with Staff 20 (Interim MCC Administrator) on 11/09/21. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure nutritious and palatable meals and snacks were provided in accordance with the United States Department of Agriculture (USDA) guidelines, modified special diets were appropriate to resident needs, menus were available to residents at least one week in advance, or the main facility kitchen and memory care kitchenette was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. The texture of puree foods prepared for residents on the memory care was found to be too thick, or too watery, putting residents at risk for choking, aspiration, and poor nutritional intake. Findings include, but are not limited to:1. The following observations and interviews were conducted between 6/1/21 and 6/4/21: * On 6/2/21 lunch consisted of sausage links, mashed potatoes, and zucchini. Pureed diets were served in Styrofoam cups. The mashed potatoes appeared thick and dry, the zucchini was runny and had a thin rim of liquid around the edge of the bowl. During an interview, Staff 18 (Care Partner) stated the kitchen prepared the pureed diets and "sometimes they seemed right but other times they are not." Staff 18 further stated she did not return the pureed food to the kitchen but would often mix the pureed food together in one bowel, so it tasted better to the resident.* During an interview, 6/3/21 at 9:36 am, Staff 16 (Dietary Services Director) confirmed the kitchen was responsible for preparing the pureed meals, and he tried to make sure residents on a pureed diet received a "nutritionally equivalent meal", but he "would pay more attention" in the future. * On 6/3/21, at approximately 5:00 pm, the pureed diets served to residents on the memory care were the consistency of water. The facilities failure to ensure modified special diets were prepared correctly and met the nutritional needs of residents put residents at risk for choking, aspiration, and potential weight loss. At 5:30 pm survey requested and immediate plan of correction to address the consistency of the pureed diets. The plan was received and accepted at 7:15 pm and the situation was abated. The need to ensure the facility served nutritious and palatable meals and snacks in accordance with USDA guidelines and modified special diets were appropriate to resident needs and of proper nutritional value was reviewed with Staff 1 (Memory Care Director) and Staff 16 on 6/4/21. 2. Resident 1, 9, 10, 11, and 12 were service planned to receive a pureed diet. Review of the residents' weight records showed each resident had lost a significant to severe amount of weight within a three to six-month period.Refer to C 270, example 23. During an interview, 6/3/21 at 1:32 pm, Witness 1 stated the family council had been requesting weekly menus since "April 2021", but had only received one for the week of May 14th. 4. On 6/1/21 the main kitchen was observed to need cleaning in the following areas:* The walls behind the rinse sink next to the dishwasher, the floor under the sink and pipes under the dish machine and sink had build-up of debris and accumulation of black matter; * Wire racks in the walk-in cooler were discolored, rusty, and the paint had been chipped off; * Entrance doors to the kitchen had chipped or missing paint; and* Entrance door to the dry storage area was gouged exposing bare wood underneath.On 6/1/21 at 10:45 am the memory care kitchenette was observed to need cleaning or repair in the following areas: * The refrigerator had a large dent on the lower part of the main door, inside of the fridge had spilled juice, food crumbs and food matter stuck to inside of the refrigerator walls; * Two lower level cabinets were missing handles, one cabinet door was crooked and did not close all the way;* The garbage can exterior including the lid had stuck on food particles, spills and drips;* The half 1/2 door into the kitchenette, walls and cupboards inside the kitchen had multiple drips, spills, black matter and stuck food particles; * The sink had clumps of black matter in the drain, food matter stuck to the side and bottom of sink basin;* The food cart was covered with food crumbs and spilled red liquid on the cart surface; * Inside and outside of microwave had smears and stuck food particles. * The glass window had streaks and food splatters on the inside and outside;* The paint on the wall behind the sink was chipped off; and * Baseboards had a build-up of thick black matter and food splatters. At 1:45 pm, the kitchenette was toured with Staff 1 (Memory Care Director), and she acknowledged the above areas were in need of clean or repair. The facilities need to ensure menus were available to residents one week in advance, and kitchens were kept clean and in good repair was discussed with Staff 1 and Staff 16 on 6/3/21 and 6/4/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide a social and recreational activity program based upon individual and group interests, physical, mental and psychosocial needs of the residents. Findings include, but are not limited to:The following observations were made between 6/1/21 and 6/4/21: * Balloon Badminton, scheduled for 6/3/21 at 4:00 pm did not take place;* There were no scheduled activities after 3:30 pm on any day of the week except for a movie at 6:00 pm; * On 6/4/21 "Happy Hour in AL" was scheduled, however there was no activity scheduled at that time for residents in the memory care; * Residents sat out in the common area for long periods of time watching movies or other TV shows, wandered the halls, or remained in their rooms; and* Staff did not provide any individualized activities to residents. During interviews on 6/3/21, Witness 1, 2 and 3 stated the following: * There should "be appropriate activities for all residents, not just movies";* Activities in recent weeks have been minimal; * On 5/26/21 at 1:20 pm "I found [resident] putting on [his/her] pajamas and getting ready for bed." "If the scheduled activities had been going on that afternoon, [resident] would have been engaged instead of abandoned to [his/her] confusion."; and* The number of activity staff had been reduced despite an increase in the number of residents. On 6/9/21, the failure to provide an activity program based on individual and group needs was reviewed with Staff 1 (Memory Care Director), Staff 3 (Executive Director), Staff 13 (VP of Memory Care) and Staff 17 (Chief Operating Officer) during the exit conference. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide services to assist the residents in activities of daily living for 4 of 5 sampled residents (#s 1, 4, 5 and 13) and unsampled residents who required oversight, cueing, supervision and assistance with ADL's. Residents were put at risk due to lack of staffing and the facility's failure to provide supervision and basic care needs. Findings include, but are not limited to:1. Resident 1 was dependent on staff for all ADL cares, including toileting and repositioning. The resident was unable to toilet or reposition independently. On 6/2/21 Resident 1 was observed sitting in his/her wheelchair from approximately 9:00 am until 1:00 pm. Staff did not provide incontinent care or reposition the resident during the observation. 2. A review of Resident 4's records indicated s/he had a history of verbal and physical aggression towards other residents. S/he had been involved in six resident to resident altercations between 1/9/21 and 5/19/21. On 6/2/21 a surveyor witnessed Resident 4 run his/her walker into an unsampled resident's right leg, causing injury. Resident 4 was saying "liar", "liar", while approaching the other resident, to which the unsampled resident responded, "isn't she a beauty." Though staff immediately responded to the altercation, two staff present in the area failed to intervene or redirect Resident 4 when the verbal exchange between the two residents started. 3. Resident 5 required assistance with bathing, toileting, and dressing. S/he also required supervision and cueing for behaviors. a. Resident 5's 5/1/21 service plan instructed staff to provide stand by assistance with bathing twice a week. Between 5/1/21 and 5/31/21, staff documented having assisted the resident with showers only twice, 5/4/21 and 5/15/21. There was no other evidence or documentation the resident had received any other showers.b. Between 6/1/21 and 6/4/21 the following was observed: * Resident wandered throughout the community in his/her socks, or with one sock on and the other foot bare. The bottom of resident's feet were visibly dirty; and* Resident engaged in several negative behaviors, including pounding on walls and doors, swearing at, or approaching other residents in an aggressive manner. Staff were either not present, or observed the behaviors but ignored them, providing no redirection or supervision. 4. Resident 13 was observed on 6/4/21 wandering in another resident's room and into the common area wearing only a soiled incontinent brief and shirt. There were no staff present to provide redirection or assistance.5. During an interview, 6/3/21, Witness 2 stated s/he typically came to visit his family member around 3:00 pm each day. S/he expressed the following concerns:* On three occasions, the resident was brought out to the common area to visit with his/her spouse and "it was obvious s/he had had a bowel movement." Witness 2 had to request staff provide incontinent care. On the third incident, resident had to wait 30 minutes because staff "were giving showers" and not available to provide care; and * Recently s/he had to request five different times to have staff cut and clean resident's fingernails, which were long, jagged and had accumulated dirt under the fingernails. 6. Observations conducted between 6/1/21 and 6/4/21 showed the following: * The facility did not have enough staff to provide supervision and care to the residents;* Several residents wandered in and out of other resident rooms, wearing other residents clothing items or taking other residents belongings;* Multiple residents walked barefoot, both inside and outside in the secured patio area. One resident was observed wearing a sock on his/her left foot and the left shoe on his/her right foot; * Non- ambulatory residents requested help from surveyors several times stating, "I need to go to the bathroom" or "help me". Staff were either not present or there were not enough staff to assist with transfers; and* During meals, residents were observed eating non-finger food items with their fingers, spilling food onto themselves, attempting to drink pureed foods, wandering during meals, spilling drinks, or not eating at all. On 6/4/21 at 4:20 pm, the survey team requested an immediate plan of correction requesting facility management provide additional oversight during resident meals and in the common area of the memory care. The plan was received and accepted at 8:00 pm, and the situation was abated. The failure to ensure adequate staffing, oversight, cueing and assistance with ADLs was shared with Staff 1 (Memory Care Director), Staff 2 (Resident Care Coordinator) and Staff 3 (Executive Director) on 6/3/21, 6/4/21 and 6/9/21. They acknowledged the findings.

4. Resident 5 was admitted to the facility in 4/2021 with diagnoses including dementia. Resident 5's move-in evaluation failed to address the following:* Customary routines;* Social and leisure interest;* Behaviors and effective non-drug interventions;* Personality, including how the person copes with challenging situations;* Recent losses;* Ability to understand and be understood;* Nutrition habits; and* Environmental factors that impact the residents behavior.The need to ensure new move in evaluations addressed all required components was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 6/3/21. 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 2 of 2 sampled residents (#s 3 and 5), and failed to complete quarterly evaluations for 2 of 2 sampled residents (#s 2 and 4), whose records were reviewed. Findings include, but are not limited to:1. Resident 2's quarterly evaluation had been completed on 6/18/20. The next quarterly evaluation was due respectively no later than 9/18/20 and continued to be updated every 90 days.There was no documented evidence a recent quarterly evaluation had been completed as of 6/3/21.The need to ensure a quarterly evaluation was completed timely was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 6/3/21. They acknowledged the findings.2. Resident 3 was admitted to the facility in 3/2021. Resident 3's move-in evaluation failed to address the following:* Transportation;* Emergency evaluation ability;* Environmental factors that impact the residents behavior;* Noise;* Lighting; and* Room temperature.The facilities failure to complete all required elements for Resident 3's new move -in evaluation was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 6/3/21. They acknowledged the findings.
3. Resident 4's record was reviewed during survey and identified the following deficiencies:* The 30 day evaluation was completed on 11/2/20. The quarterly evaluation would have been due on 2/2/21 and again on 5/2/21. There was no documented evidence of any evaluation completed after 11/2/20. On 6/9/21, the need to ensure quarterly evaluations were completed quarterly was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator). They acknowledged the findings.

6. Resident 2's service plan, dated 6/18/20, and subsequent temporary service plans were reviewed during the survey and was either not followed or failed to provide specific instruction to staff in the following areas: * Offering diet coke at lunch;* Providing shower as scheduled;* Walking exercise with the resident Q 2 hours;* 1 on 1 supervision and/or assistance during the meal;* Providing frequent verbal cues to eat at a slower rate;* Encourage to take a sip of water/juice after 1 or 2 bites; and * Risk of fall and Fall interventions.The need to ensure resident service plans were provided specific instruction to staff and followed the service plan was discussed with Staff 1 (Memory Care Director), Staff 2 (Resident Care Coordinator) on 6/3/21 and 6/9/21. They acknowledged the findings.
5. A review of Resident 4's record identified the following deficiencies: * The record indicated Resident 4 was involved in six resident to resident altercations from 1/1/21 through 6/1/21. The facility failed to develop a service plan related to resident to resident behaviors and identify interventions related to behaviors. The failure led to a resident to resident altercation with an unsampled resident on 6/2/21 which was witnessed by surveyors. On 6/4/21 the survey team requested an immediate plan of correction to update the service plan related to resident behaviors and interventions. At approximately 8:00pm the survey team received and accepted the plan.* The most current service plan was reviewed and identified as being updated on 11/2/20. The facility failed to update the service plan;* On 6/1/21, the resident was served strawberries during lunch. The service plan indicated that the resident had an allergy to strawberries that give the resident a rash; * On 6/1/21, the resident was served a salad during lunch. The service plan indicated that foods such as salads should be avoided due to colitis when they were younger;* Service plan failed to provide information related to the resident nail care needs; and* Service plan indicated that the resident is a two person stand by assist for showers, twice weekly. The shower log provided no evidence the resident was showered for the month of May 2021.On 6/9/21, the need to ensure service plans were reflective of current resident care needs, provided clear direction to staff regarding the delivery of services, ensuring the implementation of services identified on the service plan, and were updated following completion of quarterly evaluations was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of current resident care needs, provided clear direction to staff regarding the delivery of services, ensured the implementation of services identified on the service plan, or were updated quarterly for 10 of 15 sampled residents (#s 1, 2, 4, 5, 6, 7, 8, 10, 13 and 14) whose service plans were reviewed. Resident 4 had repeated physical altercations with other residents. Resident 1 did not receive basic care after a leg injury. Resident 5 eloped from the facility three times in a 30 day period. Residents 6, 7, 8, 10, 13 and 14 experienced weight loss. Findings include, but are not limited to:1. Resident 1 was admitted to the facility 1/2014 with diagnoses including Alzheimer's disease.Resident 1 was dependent on staff for all care, including requiring a two-person transfer with a Hoyer, feeding assistance, repositioning and toileting. a. On 5/26/21, resident was diagnosed with fractures of the "distal fibula and tibia" of the right ankle. A temporary service plan (TSP) dated the same day instructed staff to:* Elevate ankle "at 48 degrees at all times";* Ice ankle every 3 hours for 30 minutes at a time "for next 48 hours"; and* "Knee immobilizer to remain in place at all times". * On 6/1/21, 6/2/21 and 6/3/21, the resident was observed sitting in his/her wheelchair for breakfast and lunch meals, and then assisted to bed after 1:00 pm. There was no observation of a knee immobilizer, and resident's right leg was not elevated while in the wheelchair. * On 6/2/21, the resident was observed sitting in his/her wheelchair from approximately 9:00 am until 1:00 pm. Throughout the observation period the residents head was tilted to the left, at times almost touching his/her shoulder. Staff did not reposition the resident, offer food or fluid between meals, or provide incontinent care. * On 6/2/21 at 4:01 pm, Staff 2 (Resident Care Coordinator) confirmed she had not updated the residents service plan and stated, "I haven't gotten any instruction on what do after the first 48 hours after the injury."* On 6/3/21 at 3:45 pm, Staff 9 (Care Partner) stated staff "typically put [Resident] in bed after each meal", but with his/her "broken leg" they have been keeping the resident in bed on the evening shift, including feeding him/her dinner in bed. Staff 9 further stated "I'm really not sure how we are supposed to be taking care of [Residents name] past the first 48 hours" because there were no service plan updates to give them direction. The failure of the facility to update the resident's service plan resulted in the resident spending extended periods of time in his/her wheelchair or bed without receiving basic care or repositioning.On 6/4/21 at 10:40 am, the survey team requested an immediate plan of correction to update the residents service plan. The facility was directed to provide clear instruction to staff regarding care and services to be provided to the resident while s/he recovered from the leg injury. At 6:12 pm, the surveyors received and accepted the plan and the situation was abated. b. Resident 1's most recent service plan, dated 4/26/21, and subsequent TSP's failed to reflect residents current care needs and lacked clear instruction to staff in the following areas: * Grooming and hygiene;* Toileting frequency;* Current routines; * Finger foods;* Signs and symptoms of depression, including history of treatment and non-drug interventions;* Mobility aids; * Ability to use the call light;* Food and fluid preferences;* Bathing;* Fall risk and interventions;* Pain, including non-verbal signs of pain and non-drug interventions; and * Positioning and support of resident's head while in wheelchair. The need to ensure resident service plans were updated with changes and provided clear instruction to staff on the delivery of services was discussed with Staff 1 (Memory Care Director), Staff 2 (Resident Care Coordinator), and Staff 3 (Executive Director) on 6/3/21, 6/4/21 and 6/8/21. They acknowledged the findings. 2. Resident 5 was admitted to the facility 4/2021 with diagnoses including dementia. a. A review of resident's clinical records for the period 4/29/21 through 6/4/21, showed the resident had eloped from the facility on 5/6/21, 5/9/21 and 5/18/21. Resident's 4/29/21 move in evaluation indicated the resident was an elopement risk and stated the resident had "left home many times." Resident's 5/1/21 service plan stated resident had "minimal wandering issues" "[Residents name] has current history of wandering that does not jeopardize safety."There was no evidence the facility had updated the residents service plan after the 5/6/21 or 5/9/21 elopements. On 6/4/21 at 10:40 am the survey team requested an immediate plan of correction to update the residents service plan to accurately reflect the resident's elopement risk. At 6:12 pm, the surveyors received and accepted the plan and the situation was abated.b. Resident 5's 5/1/21 service plan was not reflective of the residents current care needs and lacked clear instruction to staff in the following areas: * Staff were instructed to provide "stand by assistance with showers twice a week", but provided conflicting information stating showers would be Monday, Thursday, Wednesday and Saturday. * Behaviors and interventions;* Risk of elopement;* Customary routines, including sleep schedule;* Personality, including how s/he copes with change or challenging situations; * Ability to use the calls system;* Environmental factors that might affect the resident's behavior; and* Reluctance to accept care from female staff. 3. Residents 6 and 7 were identified to have weight loss and Resident 10, 13 and 14 were identified to have had a significant to severe weight loss between 1/1/21 and 6/9/21. Residents most recent service plans and subsequent temporary services plans were reviewed. The following deficiencies were identified:a. Resident 6 had a six-month weight loss of 11 lbs., or 6.67% of their total body weight.The most recent service plan, dated 7/7/20, stated resident had a history of dehydration, s/he did not always eat breakfast, and the resident had "half of [his/her] stomach removed". There was no evidence the service plan had been updated since 7/7/20.b. Resident 7 had a three-month weight loss of 8 lbs., or 5.0% of their total body weight.The resident was identified during the entrance conference as receiving hospice services.The facility was unable to locate the residents service plan prior to survey exit. c. Resident 10 had a six-month weight loss of 13 lbs., or 11.40% of their total body weight. Residents 2/10/21 service plan instructed staff to report to the med tech if the resident ate less than 50 % of his/her meal. During an interview, 6/4/21, Staff 5 (MT) confirmed the facility only tracked if a resident was in attendance, not the actual percentage of food eaten. There were no further updates to the service plan in the resident's record. d. Resident 13 had a six-month weight loss of 23 lbs., or 14.8 % of their total body weight.* A temporary service plan (TSP) dated 1/7/21, stated the resident was on a regular diet and instructed staff to report "any changes in eating." * A TSP dated 5/20/21, instructed staff to "serve the resident first at meals."e. Resident 14 had a three-month weight loss of 9.8 lbs. or 8.0 % of their total body weight.The failure of the facility to conduct quarterly service plan reviews, update service plans when a resident experienced a change in care needs, or provide clear instruction to staff on the deliver of services resulted in multiple residents experiencing a significant to severe weight loss. On 6/8/21 at 11:47 am the survey team requested an immediate plan of correction to update the above residents service plans, to include information to staff about each residents nutrition and hydration needs and to ensure resident's needing assistance with eating their meals were assigned to specific staff members who would provide the assistance. At 6:52 pm, the survey team received and accepted the plan, and the situation was abated. The need to ensure resident service plans were updated quarterly, accurately reflected residents care needs, and provided clear instruction to staff on the delivery of services was discussed with Staff 1 (Memory Care Director), Staff 2 (RCC) and Staff 3 (Executive Director) on 6/3/21, 6/4/21 and 6/8/21. They acknowledged the findings. 4. Resident 8 was admitted to the facility 2/2018 with diagnosis including dementia. A review of resident 8's service plans, temporary service plans and progress notes 2/1/21 through 6/4/21 indicated the resident had a three-month weight loss of 23 lbs., or 15.03% of their total body weight.The residents most recent service plan was dated 3/3/21, however was not reflective of current care needs and did not provide clear direction to staff in the following areas: * Overall decline in physical health and increase in ADL care needs;* Staff assistance with meals;* Health shakes and frequency;* Pain areas and treatment;* Toileting assistance; and * Bathing assistance. The need to ensure resident service plans were updated quarterly, accurately reflected residents care needs, updated when a resident experienced a change in care needs, and provided clear instruction to staff on the delivery of services was discussed with Staff 1 (Memory Care Director), Staff 2 (Resident Care Coordinator) and Staff 3 (Executive Director) on 6/3/21, 6/4/21 and 6/8/21. They acknowledged the findings.

2. Resident 14 was admitted to the memory care in April 2021 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's clinical record, including review of the service plan, dated 08/10/21, and interim service plans (ISP's) showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, was not accurate, or contained inconsistent instruction to staff in the following areas:* Two person transfers;* Wheelchair use as a mobility device; * Resident specific activity preferences; and * Resident specific nutrition and hydration plan.The need to ensure service plans were reflective and included clear direction to staff was discussed with Staff 20 (Interim MCC Administrator) on 11/10/21. 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, for 2 of 3 sampled residents (#s 14 and 16) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 16 was admitted to the memory care in April 2021 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's clinical record, including review of the service plan, dated 09/22/21, and interim service plans (ISP's) showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, was not accurate, or contained inconsistent instruction to staff in the following areas: * Communication, including hearing;* Toileting schedule;* Transfer assistance;* Dressing assistance;* Time frame for safety checks;* Weight loss;* Emergency evacuation ability, * Elopement risk, history;* Environmental factors that could impact behavior; and* Fall risk and interventions. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 20 (Interim MCC Administrator) and Staff 22 (RCC) on 11/09/21 and 11/10/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 4 of 4 sampled residents (#s 1, 2, 4 and 5). Findings include, but are not limited to:Resident 1, 2, 4 and 5's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.On 6/9/21, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 3 sampled residents (#s 14, 16 and 17). This is a repeat citation. Findings include, but are not limited to:Residents 14, 16 and 17 resided in the MCC during the revisit survey.Their most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development.The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 20 (Interim MCC Administrator) and Staff 22 (RCC) on 11/10/21. They acknowledged the findings.

4. Resident 2 was admitted to the facility in 2017 with diagnoses including vascular dementia with depressive mood, secondary Parkinson's disease and gait abnormality.Observations of the resident from 6/1/21 to 6/4/21 showed the resident required 2-person assistance with transfers and incontinent care.a. Resident 2's 3/16/21 and 3/23/21 Temporary Service plan indicated the resident was a "high risk for fall" due to increased weakness and instructed staff to encourage the resident to use wheelchair for ambulation, "2-person assist with transfer until evaluation" and staff to "please move dining chair behind res [resident] instead of having (his/her) spin around to sit down."Progress notes and incident reports dated 2/5/21 through 5/31/21 indicated the following: * On 4/8/21, staff documented on a facility incident report that "the resident walking with walker to chair. When [he/she] got close to chair, [his/her] knees locked up and [staff] assisted [him/her] to floor."; * On 4/11/21, staff noted "Res [resident] was being sat onto chair and res [resident] sat too soon and sat on arm of chair and slide down to floor."; * On 4/19/21, staff documented on a facility progress note that the resident had fall in the restroom when transferring from toilet into the wheelchair. There was no incident report for the fall; and * On 5/20/21, staff documented on a facility incident report that the resident had fall during the transfer and missed the wheelchair. A review of the facility incident reports, 4/8/21, 4/11/21 and 5/20/21, revealed there was no documented evidence the facility thoroughly reviewed each incident to determine if service planned interventions were followed in the area of 2-person assisting with transfers and moving a chair behind of the resident when sitting nor was there evidence the interventions were evaluated for effectiveness.On 6/3/21 and 6/8/21, the above findings were reviewed with Staff 1 (Memory Care Director), Staff 2 (Resident Care Coordinator) and Staff 3 (Executive Director). The staff acknowledged the findings.b. Resident 2's clinical records dated 2/5/21 through 5/31/21 were reviewed during the survey and revealed the following: * On 2/16/21 and 2/16/21, Right side back pain with a new as needed lidocaine medication for the pain; * On 3/23/21, Increased weakness; * On 3/5/21 and 4/14/21, Increased dose of Tylenol and Zyprexa (to treat mental disorder); and * On 3/26/21, Edema on legs.There was no documented evidence that the resident's short-term changes of condition were consistently monitored weekly to resolution. On 6/3/21 and 6/9/21, the above information was discussed with Staff 1 (Memory Care Director), Staff 2 (Resident Care coordinator) and Staff 3 (Executive Director). The staff acknowledged the findings.
5. Resident 4 was admitted to the facility in 2020 with diagnoses including dementia.a. Resident 4's record was reviewed for changes of condition and revealed the following:* On 3/30/21 -Placed on alert monitoring for an increase in sertraline (a medication to treat for depression) and the start of methylsalicylate cream (for headache).* On 5/15/21 -Placed on alert monitoring for being found on the floor from an unwitnessed non-injury fall.There was no documented evidence the medication changes were monitored weekly. The medication changes and the non-injury fall lacked documentation they were monitored until resolution. b. Resident 4 was involved in seven resident to resident altercations from 1/9/21 through 6/1/21. The facilities interventions were increased safety checks, monitor, and redirect resident. The facility failed to monitor the effectiveness, and failed to develop new interventions when pervious interventions failed. On 6/2/21, the surveyor witnessed Resident 4 engage in a verbal and physical altercation with another resident. Resident 4 ran his/her walker into an unsampled residents leg, causing a one inch by one inch raised bump and bruise. After Resident 4 hit the other resident with his/her walker, both residents began hitting each other and fell to the floor. On 6/9/21, the need to ensure changes of condition were monitored weekly until resolution and the need to ensure that interventions are being monitored and documented for effectiveness was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure residents who had a significant change of condition were evaluated, monitored and/or referred to the RN for 2 of 2 sampled residents (#s 1 and 2), failed to monitor and document weekly progress of a short-term change of condition until the condition resolved, or monitor the effectiveness of interventions developed for 3 of 3 sampled residents (#s 2, 4 and 5), and failed to evaluate, monitor, develop resident specific interventions or refer to the RN for an assessment for 9 of 9 residents (#s 6, 7, 8, 9, 10, 11, 12, 13, and 14) reviewed for weight loss. Residents 1 experienced severe pain due to an injury. Residents' 6, 7 experienced weight loss. Residents 8, 9, 10, 11, 12, 13 and 14 experienced significant weight loss. Findings include, but are not limited to:1. Resident 1 was admitted to the facility 1/2014 with diagnoses including Alzheimer's disease. Resident was dependent on staff for all ADL care, was a two-person transfer with a Hoyer, and was primarily non-verbal.Resident 1's service plan, temporary service plans, progress notes, incident reports, 5/1/21 through the 5/31/21 MARs, physician communications and hospital discharge orders were reviewed and showed the following: * On 5/23/21, staff discovered bruising to the lower right abdomen, left arm and swelling and bruising to the resident's right ankle. Staff documented the resident "screamed in pain" during cares;* A TSP written the same date instructed staff to monitor for pain, worsening of injury, or change in range of motion, and to conduct two hour safety checks, "avoid moving [resident] foot as much as possible" and "Take your time with cares. Do not rush through them.";* On 5/23/21, staff documented they had contacted the on-call physician, who prescribed acetaminophen 500 mgs three times a day and as needed for pain management;* On 5/24/21, "residents bruise on [his/her] foot has got worse. Bruise is now covering whole foot. Resident still having pain when foot is moved." "Have not heard back from physician.";* On 5/25/21, "notify PCP if pain and bruising persists." "Swelling and bruising is incredibly worse than before." "[physician] said they'd be ordering a mobile X-rays stat.";* On 5/25/21, the facility RN documented in a late entry for 5/24/21 the following:"This RN looked at it yesterday and ankle and foot appeared reddish/brown on both medial and lateral ankle and slight dorsal redness and swelling." " ...today the area has worsened, with more discoloration and swelling." Residents pain was described as follows:* 5/23/21 " ...while changing [his/her] brief resident screamed in pain";* 5/24/21 "Resident still having pain when foot is moved";* 5/25/21 "Resident does wince and cry out if [right] foot is moved"; * 5/25/21 "Right food is extremely painful ..."; and * 5/26/21 "[Resident] moaned with pain when care staff were doing cares."* On 5/26/21, the resident was diagnosed with two fractures in his/her right ankle and sent to the emergency department (ED) for treatment and pain management. The resident returned to the facility the same day with a cast on his/her right ankle and a prescription for a narcotic pain reliever. * A TSP written the same day summarized ED discharge instructions for the first 48 hours of care, which included: elevating the ankle at all times, icing ankle every three hours for 30 minutes, knee immobilizer to remain in place at all times. * 5/28/21, Staff 2 (Resident Care Coordinator) completed a "change of condition evaluation." Under the category "How does the resident express pain?" Staff 2 documented "Non-verbal signs of pain" "Right leg at ankle". No other information was documented in the evaluation regarding the resident's injuries, pain, pain management, or ankle fracture. During an interview on 6/2/21, Staff 2 confirmed she had not updated the resident's service plan because she did not know what instruction to give to staff after the "first 48 hours." On 6/3/21 at 3:45 pm, Staff 9 (Care Partner) stated before the resident broke his/her ankle, staff would transfer him/her into the shower for bathing, escort the resident to all meals in the dining room, and assist the resident to bed in between meals. Staff now put the resident to bed after lunch and fed him/her dinner in bed. There was no documented evidence the facility had thoroughly evaluated the severity of the injury or residents pain level, developed actions or interventions for the treatment of the injury other than over the counter pain management, or updated the residents service plan to include specific instruction to staff on how to provide care for the resident while s/he was recovering. The facility's failure to thoroughly evaluate the resident's injury and pain level, failure to develop actions or interventions to treat the injury or address the residents pain, and failure to provide specific instruction to staff, resulted in the resident experiencing extreme levels of pain, a delay in treatment of the injury and inadequate care. The need to ensure residents who experience a significant change of condition were evaluated and resident specific actions or interventions were developed and communicated to staff was discussed with Staff 1 (Memory Care Director) and Staff 2 on 6/3/21. They acknowledged the findings. No further information was provided. 2. On 6/4/21, survey requested a copy of six months of weight records for all residents in the memory care. On 6/8/21, Residents 6, 7, 8, 9, 10, 11, 12, 13 and 14 were identified with weight loss. A review of weight records revealed the following: a. Resident 6 experienced a weight loss between 1/1/21 (120 lbs.) and 6/8/2 (110 lbs.) of 11 lbs., or 8.33 % of his/her total body weight. b. Resident 7 experienced a weight loss between 3/4/21 (160.2 lbs.) and 5/4/21 (152 lbs.) of 8 lbs. or 5 % of his/her total body weight.c. Resident 8 experienced a severe weight loss between 2/19/21 (153 lbs.) and 5/4/21 (130 lbs.) of 23 lbs. or 15.03 % of his/her total body weight. d. Resident 9 experienced a significant weight loss between 1/5/21 (114 lbs.) and 6/1/21 (100 lbs.) of 14 lbs. or 12.28 % of his./her total body weight. e. Resident 10 experienced a weight significant loss between 1/4/21 (114 lbs.) and 6/1/21 (101 lbs.) of 13 pounds or 11.40 % of his/her total body weight. f. Resident 11 experienced a significant weight loss between 2/3/21 (112 lbs.) and 4/4/21 (102 lbs.) or 8.93 % of their total body weight;g. Resident 12 experienced a weight loss between 1/1/21 (151 lbs.) and 6/1/21 (131 lbs.) or 13.25 % of his/her total body weight. h. Resident 13 experienced a weight loss between 1/1/21 (155 lbs.) and 6/4/21 (132 lbs.) or 14.8 % of his/her total body weight.i. Resident 14 experienced a weight loss between 4/5/21 (121.6 lbs.) and 6/4/21 (111.8 lbs.) or 8.0 % of his/her total body weight.There was no documented evidence in the residents records the weight loss had been evaluated, actions or interventions had been determined to address the weight loss and communicated to staff, the facility was monitoring for subsequent weight loss, or had referred to the RN for a significant change of condition assessment. During an interview, 6/4/21, Staff 14 (RN) confirmed she had not been monitoring residents weights, and was not aware of the significant weight loss. The facilities failure to have a monitoring system in place to review residents weights and weight loss lead to multiple residents losing a significant to severe amount of weight. The facilities failure to have a system in place to monitor, evaluate, develop actions or interventions and communicate those actions and interventions to staff, and the failure to report a residents significant change of condition to the RN was discussed with Staff (1) (Memory Care Director), Staff 2 (Resident Care Coordinator) and Staff (3) (Executive Director) on 6/4/21 and 6/8/21. They acknowledged the findings. No additional information was provided.3. Resident 5 was admitted to the facility 4/2021 with diagnoses including dementia. Residents service plan, temporary service plans, progress notes and incident reports were reviewed and showed the following: Resident 5's 5/1/21 service plan described the resident as "cooperative" and stated the resident had "No behavior issues" "[Residents name] does not have current or history of disruptive, aggressive, verbal or socially inappropriate behavior."* Resident had eloped from the facility on 5/6/21, 5/9/21 and 5/18/21; and * Resident repeatedly engaged in aggressive behaviors towards other residents.Resident 5's 5/1/21 service plan described the resident as "cooperative" and stated the resident had "No behavior issues" "[Residents name] does not have current or history of disruptive, aggressive, verbal or socially inappropriate behavior."A TSP, written 5/19/21, identified the resident as an elopement risk, and instructed staff to "make sure doors shut behind you" when going in or out, and "Family's aware not to let anyone out when coming and going. There was no documented evidence the facility had determined actions or interventions to address the elopements prior to 5/19/21, and no evidence the facility had actions or interventions to address the resident's aggressive behaviors. The need to ensure the facility determined and documented resident specific actions or interventions needed to address a residents condition, and communicated the determined actions and interventions to staff was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) on 6/4/21 and 6/8/21. They acknowledged the findings. (Refer to Z 165)

3. Resident 2 was admitted to the facility in 2017 with diagnoses including vascular dementia with depressive mood, secondary Parkinson's disease and gait abnormality.Observations of the resident from 6/1/21 to 6/8/21 showed the resident required 2-person assistance with transfers and incontinent care.During the acuity interview, the resident was identified to have a decline in condition in multiple areas including mobility and ADL assistance due to increased weakness and multiple falls.The resident's clinical record was reviewed, and revealed the following:The resident experienced nine falls between 2/2021 and 5/2021 that resulted in pain and redness on skin;The resident's 3/23/21 Temporary Service plan indicated the resident was a "high risk for fall" due to increased weakness and instructed staff to encourage the resident to use wheelchair for ambulation and 2-person assist with transfer.During the survey, Staff 12 (MT) and Staff 18 (Care Partner) reported the resident had an overall decline in status for last 1 - 2 months in the following areas:* No longer ambulating independently with a walker, use of wheelchair;* No longer transfer independently, needing 2-person assistance with transfer; and* Required staff assistance or supervision in ADLs including toileting and meal intake.Resident 2's changes represented a significant change of condition.There was no documented evidence the facility RN conducted an assessment of the resident's overall status which included findings, a description of the resident status and interventions made as a result of the assessment.The failure to conduct an RN assessment following a significant change in status was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator) during the survey. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, or updated the service plan for 2 of 2 sampled residents (#s 1 and 2) who experienced a significant change of condition, and 9 of 9 residents (#s 6, 7, 8, 9, 10, 11, 12, 13, and 14) reviewed for weight loss. Resident 1 was placed at risk for serious harm due to the facility's failure assess the severity of an injury or severe pain. Residents 6, 7, 8, 9, 10, 11, 12, 13, and 14 experienced significant weight loss. Findings include, but are not limited to:1. Resident 1 was admitted to the facility 1/2014 with diagnoses including Alzheimer's disease. Resident was dependent on staff for all ADL care, was a two-person transfer with a Hoyer, and was primarily non-verbal. * On 5/23/21, staff discovered bruising to the lower right abdomen, left arm and swelling and bruising to the resident's right ankle. On 5/26/21, the resident was diagnosed with two fractures in his/her right ankle and sent to the emergency department (ED) for treatment and pain management. * On 5/25/21, the RN documented "This RN looked at it yesterday and ankle and foot appeared reddish/brown on both medial and lateral ankle and slight dorsal redness and swelling." " ...today the area has worsened, with more discoloration and swelling." * Progress notes indicate the resident was in a severe amount of pain from 5/23/21 to 5/26/21 when s/he was prescribed a narcotic in the emergency department. * On 6/1/21, Staff 2 (Resident Care Coordinator) provided survey with a document labeled "RN Change of Condition". The document summarized the discharge instructions provided by the emergency department for the first 48 hours of care, however failed to assess the residents condition or pain, and contained no interventions or plan of care. The document was not signed or dated by the RN. * During an interview, 6/2/21, Staff 2 stated the RN would hand write a change of condition assessment, then give it to Staff 2 to type and put in the resident's chart. The facility RN was not available for interview. There was no other assessment in the residents chart. The RN's failure to assess Resident 1 for a change of condition, delayed treatment of injury and caused the resident to experience severe and untreated pain.The lack of an RN assessment regarding Resident 1's significant change in condition was reviewed with Staff 1 (Memory Care Director), Staff 3 (ED), Staff 13 (VP of Memory Care) and Staff 17 (Chief Operating Officer) during the exit conference. No further information was provided. Refer to C 270, example 12. A review of Residents' 8, 9, 10, 11, 12, 13 and 14's weight records revealed each resident had lost a significant to severe amount of weight. During an interview, 6/4/21, Staff 14 (RN) confirmed she had not been monitoring resident's weights. There was no documented evidence the RN had assessed any of the residents for weight loss. The facility's failure to implement an effective system for monitoring residents' weights lead to multiple residents experiencing significant weight loss. The lack of an RN assessment regarding multiple residents identified with weight loss, was reviewed with Staff 1 (Memory Care Director), Staff 3 (ED), Staff 13 (VP of Memory Care) and Staff 17 (Chief Operating Officer) during the exit conference. No further information was provided.Refer to C 270, example 2

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (#3) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:During the acuity interview on 6/1/21, Resident 3 was identified to be administered insulin injections by non-licensed staff.Delegation records and 5/1/21 - 5/31/21 MAR for Resident 3, were reviewed on 6/2/21 and revealed the following:1. There was no current RN assessment to determine that Resident 3's condition remained stable and predictable prior to deciding to delegate;2. Staff 5, 7 and 12's (MTs) transfer of delegation was completed on 4/21/21. The current facility RN accepted the outgoing RN's plan for supervision of Staff 5, 7 and 12. a. Staff 5 documented on the MAR she administered Resident 3's insulin injection on 5/1/21, 5/4/21, 5/5/21 and 5/6/21. The last evaluation for Staff 5's skills and ability was completed on 3/24/21 and scheduled for re-evaluation on 5/24/21. There was no documented evidence of re-evaluation of the delegation task for Resident 3 had been completed as of 6/2/21.b. Staff 7 documented on the MAR she administered Resident 3's insulin injection on 5/2/21, 5/12/21, 5/13/21,5/19/21, 5/20/21, 5/26/21 and 5/27/21. The last evaluation for Staff 7's skills and ability was completed on 3/24/21 and scheduled for re-evaluation on 5/24/21. There was no documented evidence of re-evaluation of the delegation task for Resident 3 had been completed as of 6/2/21.c. Staff 12 documented on the MAR she administered Resident 3's insulin injection on multiple days, approximately 20 days, in 5/2021. The last evaluation for Staff 12's skills and ability was completed on 3/30/21 and scheduled for re-evaluation on 5/30/21. There was no documented evidence of re-evaluation of the delegation task for Resident 3 had been completed as of 6/2/21.On 6/2/21 and 6/3/21, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Memory Care Director) and Staff 14 (RN/Health Service Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication administration system was in place for all residents and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:During the survey, conducted 6/1/21 through 6/4/21, concerns were identified in medication administration system, including medication administration timeframe's and staff adherence the facility's policy and procedure.1. The 5/1/21 - 5/31/21 MARs for 3 of 3 sampled residents (#s 1, 2 and 4) indicated their medications could be administered in AM (morning), late AM, evening and HS (at bedtime).In an interview on 6/1/21, Staff 7 (MT) stated the residents' medications could be given anytime within the following timeframes:* "AM" medications could be given between 6:00 am and 9:00 am; * "Late AM" medications could be given between 10:00 am and 1:00 pm; * "Evening" medications could be given between 3:00 pm and 6:00 pm; and* "HS" (bedtime) medications could be given between 6:00 pm and 10:00 pm. The facility policy for Medication Services dated 7/7/2020 indicated "Medications may be given up to one hour before or up to one hour after the prescribed time to accommodate resident schedules, unless the physician orders an exact time."Review of Resident 1, 2 and 4's 5/1/21 through 5/31/21 MARs revealed the following:* AM medications were given between 6:18 and 10:45 am;* Late AM medications were given between 10:42 am and 1:16 pm; * Evening medications were given between 2:59 pm and 5:15 pm; and* HS medications were given between 6:24 pm and 7:39 pm. 2. Resident 1's 5/1/21 - 5/31/21 MAR revealed the following:* Instructed to administer Tylenol 500 mg three times daily; and* On 5/13/21, the AM dose of Tylenol was given at 10:44 am and the second dose was given at 11:44 am, one hour later. 3. Resident 2's 5/1/21 - 5/31/21 MAR revealed the following:a. Instructed to administer Lorazepam 0.5 mg three times daily. On 5/5/21 the AM dose of Lorazepam was given at 6:23 am and the late AM dose was given at 13:16 (1:16 pm), 6 hours and 53 minutes later and the evening dose was given at 15:25 (3:25 pm) 2 hours 9 minutes later.b. Instructed to administer Tylenol 500 mg three times daily. On 5/5/21 last AM dose of Tylenol was given at 13:16 (1:16 pm) and the evening dose was given at 15:24 (3:24 pm), 2 hours and 8 minutes later.This represented an unsafe medication administration system because it did not address time-sensitive medications (those where early or delayed administration of maintenance doses of wide spread scheduled dose may result in substantial sub-optimal therapy or pharmacological effect) and did not prevent medications from being administered too close together since several of the timeframes overlapped.4. During the survey administrative oversight of the medication and treatment administration system was found to be ineffective based on deficiencies in the following areas:* C 303: Medication and Treatment Orders;* C 304: Medication and Treatment Review; and * C 310: Medication Administration.The need to ensure the facility had a safe medication administration system and the overall medication and treatment administration system were reviewed with Staff 1 (Memory Care Director), Staff 3 (Executive Director), Staff 13 (VP memory care) and Staff 17 (Chief Operating Officer) on 6/9/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 4 sampled residents (# 2) whose orders were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 2017 with dementia with depressive mood, and secondary Parkinson's disease. Resident 2 had a physician's order, dated 3/5/21, to administer Milk of Magnesia 30 ml if no bowel movement on 3rd day.Resident 2's 5/1/21 through 5/31/21 bowel record reviewed and revealed the resident had no bowel movement from 5/10/21 - 5/12/21 for 3 days, 5/16/21 - 5/18/21 for 3 days and 5/23/21 - 5/28/21 for 6 days.Resident 2's 5/1/21 through 5/31/21 MAR revealed the medication was not administered on those days when the resident had no bowel movement on 3rd day without clear documentation of why.On 6/3/21 and 6/9/21, the above finding was shared with Staff 1 (Memory Care Director), Staff 2 (Resident Care Coordinator), Staff 3 (Executive Director), Staff 13 (VP memory care) and Staff 17 (Chief Operating Officer). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a registered pharmacist or registered nurse reviewed all medications and treatments administered to residents by the facility, at least every 90 days for 3 of 3 sampled residents (#s 1, 2 and 4). Findings include, but are not limited to:Residents 1, 2 and 4's records were reviewed and showed a lack of documented pharmacist or RN reviews. On 6/3/21, Staff 2 (Resident Care Coordinator) confirmed the medications and treatments orders were not reviewed by a registered pharmacist or registered nurse every 90 days. The need to ensure a pharmacist or an RN reviewed medication and treatments administered by the facility at least every 90 days was discussed with Staff 1 (Memory Care Director), Staff 2, Staff 3 (Executive Director), Staff 13 (VP memory care) and Staff 17 (Chief Operating Officer) on 6/3/21 and 6/9/21. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and provided clear instruction and parameters for administration of PRN medications for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:1. Review of Resident 4's MAR, between 5/1/21 - 6/1/21, identified the following deficiencies:The following medications lacked reasons for use on the MAR:*Quetiapine 25mg;*Quetiapine 12.5mg;*Sertraline 75mg; and *PRN Polyethylene glycol 3350 powder.As needed Polyethylene glycol powder also lacked parameters for when to administer the medication.On 6/9/21, the need to ensure residents' MARs were accurate and provided clear instruction and parameters for administration of PRN medications was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator). They acknowledged the findings.
4. Review of Resident 5's MAR, 5/1/21 through 6/1/21, identified the following medications lacked a reason for use: *Omeprazole; Quetiapine 25mg; and*Quetiapine 25mg.On 6/9/21, the need to ensure residents' MARs were accurate and contained a reason for use was discussed with Staff 1 (Memory Care Director), Staff 3 (ED), Staff 13 (VP of Memory Care) and Staff 17 (Chief Operating Officer) during the exit conference. They acknowledged the findings.5. Resident 1's 5/1/21 through 6/1/21 MAR was reviewed. On 5/26/21 resident was prescribed PRN oxycodone (pain reliever). Instructions on the MAR were to administer "take 1-2 tabs every six hour", however did not clarify when to take one versus 2 tablets. The need to ensure the residents MAR contained clear instruction for PRN administration was discussed with Staff 1 (Memory Care Director), Staff 3 (ED), Staff 13 (VP of Memory Care) and Staff 17 (Chief Operating Officer) during the exit conference. They acknowledged the findings.
2. Review of Resident 2's MAR, 5/1/21 through 5/31/21, identified the following medications lacked a reason for use: *Diltiazem ER 180 mg;* Losartan 50 mg; and*Vitamin D3 2000 IU.On 6/3/21 and 6/9/21, the need to ensure residents' MARs were accurate and contained a reason for use was discussed with Staff 1 (Memory Care Director), Staff 3 (Executive Director), Staff 13 (VP of Memory Care) and Staff 17 (Chief Operating Officer). They acknowledged the findings.3. Resident 3's 5/1/21 - 5/31/21 MAR was reviewed and were found to be lacked reason for use in Lantus.On 6/3/21 and 6/9/21, the need to ensure reason for use to all medications was discussed with Staff 1 (Memory Care Administrator), Staff 2, Staff 3 (Executive Director), Staff 13 (VP memory care) and Staff 17 (Chief Operating Officer). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident, which put residents at risk for serious harm. Findings include, but are not limited to:1. During the entrance conference on 6/1/21 the following was identified: * The facility had 41 residents;* Thirteen residents needed two-person assist with transfers or Hoyer;* Nine residents were on hospice; * Five residents needed full assistance with meals; and* Multiple residents were identified with behavioral issues needing constant cueing and redirection. 2. The staffing plan provided by the facility was as follows: * Day shift 2 MAs and 3-4 CG's;* Evening shift 2 MAs and 3-4 CG's; and * Night shift 1 MA and 2 CG's. During an interview, 6/1/21 at 4:01 pm, Staff 2 (Resident Care Coordinator) confirmed she did not use an acuity-based tool to determine staffing levels, and stated "it's determined for me" then pointed to the posted facility staffing plan. When asked how she determined if she should schedule three versus four caregivers on the day and evening shifts, she responded "depends on if someone calls in sick, then it is 3".4. Staff stated the following during interviews conducted 6/1/21 through 6/4/21: * On day shift they use to have 3 to 4 caregivers, recently they have only had two caregivers and two med techs. "There have been times when night shift has not had a Med Tech."* Staffing was "terrible." Day shift usually had three instead of four caregivers, so the Med Tech would "take a section of the floor to work" but that left residents unsupervised and often medication was passed late.* Evening shift had two Med Techs scheduled Thursday, Friday and Saturday. All other evenings only one was scheduled. There were usually only three caregivers instead of four on the evening shift and it was "very tough". * "Usually on Fridays only two caregivers are scheduled to work so I usually come in on my day off." * "At least three of the five days I work we are short a caregiver."5. Observations conducted between 6/1/21 and 6/3/21 showed the following: * 6/1/21, between 11:45 am and 12:30 pm (lunch meal observation) approximately 10 residents were seated at tables located near the common TV room. Two residents who were served lunch did not eat anything and appeared to be confused with the use of silverware. Resident 13 wandered in and out of other resident's rooms, taking other residents belongings. S/he was wearing only one shoe on his/her right foot. Resident 14 laid on a couch throughout the meal. S/he was barefoot and wearing a soiled top. Staff served residents lunch at 12:40 pm, however did not stay in the area to provide supervision, cueing or redirection. * 6/2/21 from approximately 9:00 am to 1:00 pm, Resident 4 sat in his/her wheelchair with his/her head leaning to the left, no staff provided repositioning or assisted the resident with incontinent care. * 6/2/21 at 10:38 am, a male resident started yelling and swearing at a female resident in the main dining area. No staff were present to provide redirection. * 6/3/21 at 3:40 pm, an unsampled resident asked Staff 19 (Care Partner) if she could help him/her go to the bathroom. Staff 19 responded no staff was available to help her, then stated "I'm sorry [Residents name]". 6. Time clock records, 5/1/21 through 5/31/21, were requested, reviewed, and compared to the facility's May 1st through the 31st 2021 staffing schedule. * Day shift was short one staff four times, two staff seven times, and three staff three times;* Evening shift was short one staff 13 times; and * Night shift was short one staff 3 times. On 6/3/21 at 4:55 pm, the survey team requested an immediate plan of correction to address the staffing shortages. At 7:05 pm, a plan was received and accepted by the survey team. 7. Additional observations, conducted 6/4/21, showed the following: * Resident 13 was observed wandering in the common area wearing only his/her soiled incontinent product and a shirt. Staff did not immediately provide redirection or assist the resident until requested by survey. * Between 2:00 pm and 5:00 pm, several unsampled residents waved their hands or yelled to the surveyors they needed to use the restroom however no staff were available to assist resident's; * At approximately 3:00 pm one resident was found barefoot on the secured patio waving a garden hose and spraying plants and flower boxes while another resident was pulling plants up from the flower boxes and then touched his/her face; and* Resident 5 wandered the halls, to and from the patio and in and out of other resident's rooms, pounding on exit doors and swearing at residents and staff. Staff were either unavailable or failed to provide redirection, cueing or basic services to residents. The failure to ensure adequate staff to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 (Memory Care Director) Staff 2, and Staff 3 (Executive Director) on 6/3/21 and 6/4/21. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. This is a repeat citation. Findings include, but are not limited to:1. During the revisit entrance conference on 11/08/21 the following was identified: * The facility had 31 residents;* Six residents needed two-person assist with transfers; * Five residents needed full assistance with meals; and* Five residents were identified as needing full assistance with ADL's.2. The staffing plan posted by the facility at the time of the revisit matched the condition placed on the facility after the Change of Ownership survey conducted 06/09/21, and was documented as follows: * Day shift 2 MT's and 5 CG's;* Evening shift 2 MT's and 5 CG's; and * Night shift 1 MT and 3 CG's. 3. Observations and interviews at the time of survey showed the following: * During breakfast and lunch meal observations, 11/08/21, 11/09/21 and 11/10/21, a minimum of eight facility staff members were present, which included five caregivers and three administrative staff, to ensure residents were served meals on time, residents needing full meal assistance were fed, and residents needing cueing or redirecting were attended to. * In an interview, 11/09/21, Staff 20 (Interim MCC Administrator) confirmed the facility was still in the process of hiring staff and had at times been "short staffed." * On 11/10/21 Staff 22 (RCC) confirmed the facility was still short staffed "at times", stated he had worked on the floor multiple times, and further stated finding staff to work the evening shifts had been very difficult.* On 11/09/21, Staff 28 (CG) stated day shift usually had three or four caregivers, sometimes there were five. Evening shift had one less person scheduled "because there is only one meal to serve", and recently she had been assigned to work 12-hour shifts, fromt 6:00 am to 6:00 pm. 4. A review of the memory care staff schedule, 10/01/21 through 10/31/21 and 11/01/21 through 11/08/21 indicated the following: * Day shift was short one or more caregiving staff 22 times;* Evening shift was short one or more caregiving staff 35 times; and * Night shift was short one or more caregiving staff approximately 33 times. The failure to ensure adequate staff to meet the scheduled and unscheduled needs of the residents was shared with Staff 20 and Staff 22 on 11/09/21 and 11/10/21. They acknowledged the findings.

Based on interview and record review, it was determined 4 of 4 newly-hired direct care staff (#s 6, 8, 10 and 11) failed to complete First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed with Staff 1 (Memory Care Director) on 6/8/21. Staff 6 (CG) was hired 2/09/21, Staff 8 (CG) hired 4/01/21, Staff 10 (MT) was hired 1/03/21 and Staff 11 (MT) was hired 2/04/21.The facility did not have documentation that Staff 6 and Staff 8 completed the required First Aid and abdominal thrust training, and Staff 10 and Staff 11 completed the required abdominal thrust training within 30 days of hire.The need to ensure all training was completed within required timeframe's was discussed with Staff 1. She acknowledged Staff 6, 8, 10 and 11 had not completed the required training.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other months according to the Oregon Fire Code (OFC) and failed to provide fire and life safety training to staff on alternate months. Findings include, but are not limited to:Fire drills and fire and life safety training records for 1/2020 - 5/2021 were reviewed and identified the following:a. The facility failed to provide documented evidence fire and life safety instruction to staff was completed on alternating months from the fire drills; andb. The facility failed to document the following when fire drills were conducted:* Escape route used;* Problems encountered with residents who resisted or failed to participate in drills;* Evacuation time period needed; and* Number of occupants evacuated.The need to ensure the facility was in compliance with all required fire drill and fire and life safety requirements was discussed with Staff 1 (Memory Care Director) on 6/3/21. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:On 6/3/21, the facility's fire and life safety records were requested for review.There was no documented evidence of the following general fire and life safety requirements: * Evidence alternative exit routes were used during fire drills; * Evidence staff and residents participated in fire drills and training to assess ongoing evacuation capabilities of both residents and staff; and* Documentation of interventions and resolution related to resident evacuation concerns identified during fire drills.The need to ensure all general fire and life safety requirements were implemented and followed was discussed with Staff 1 (Memory Care Director) on 6/3/21. 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 C231, C260, C262, C360, Z142, Z163, Z162 and Z164.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident was clean and in good repair. Findings include, but are not limited to:During a tour of the facility on 6/1/21, the following was observed:*Multiple chairs and tables in the dining area had scuffs, scrapes, and worn off finishes, creating an uncleanable surface;*Exterior walls and doors of the MCC entrance and exterior of the MCC courtyard entrance had dirt, debris, and spider webs;*Multiple stains on the carpet through the common areas; and*Multiple scuffs and scraps on the walls in the dining room. On 6/1/21, the need to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents were clean and in good repair was discussed with Staff 1 (Memory Care Director) and Staff 15 (Maintenance Director). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:The licensee is responsible for the operation of the Memory Care Community and the provision of person-directed care that promotes each resident's dignity, independence and comfort. That includes the supervision and overall conduct of the staff.During the relicensure survey, conducted 6/1/21 through 6/9/21, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the citations issued during the survey. Refer to deficiencies in report.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 152, C 154, C 155, C 156, C160, C 200, C 231, C 240, C 242, C 360, C 372, C 420, C 422 and C 513.

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 C360.

Based on interview and record review, it was determined the facility administrator failed to acquire at least 10 hours of Continuing Education Credits (CEU's) related to the care of individuals with dementia over the last year. Findings include, but are not limited to:During the survey, Staff 1 (Memory Care Director) was requested to provide documentation of the annual continuing education training for 2020 . On 6/1/21, Staff 1 provided a print out and certificates of her annual continuing education training hours. The documentation provided lacked evidence of the required 10 hours of Division-approved training, related to care of individuals with dementia.In an interview on 6/3/21, Staff 1 stated she was not aware of the required 10 hours of annual continuing education training related to the care of individuals with dementia. On 6/3/21, the lack of training was reviewed with Staff 1. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure all required pre-service orientation, pre-service dementia training, competency training within required timelines, was completed prior beginning their job responsibilities for 3 of 3 newly hired staff (#s 8, 10 and 11) whose training records were reviewed. Findings include, but are not limited to:Training records were reviewed with Staff 1 (Memory Care Director) on 6/3/21 and 6/9/21. The following deficiencies were identified:* Staff 8 (Care Partner) was hired 4/1/21, failed to complete pre-service orientation training prior to beginning their job duties in the following areas:- Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;- Techniques for understating, communicating and responding to distressful behavioral symptoms;- Strategies for addressing social needs and engaging persons with dementia in meaningful activities;- Specific aspects of dementia car and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;- Environmental factors that are important to a resident's well-being;- Family support and the role the family may have in the care of the resident;- How to recognize behaviors that indicate a change in the resident's condition and report behaviors that required on-going assessment;- How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and- Use of supportive devices with restraining qualities in memory care communities.* Staff 10 (MT) was hired 1/3/21, failed to complete pre-service orientation training prior to beginning their job duties in the following areas:- Environmental factors that are important to a resident's well-being; and- Use of supportive devices with restraining qualities in memory care communities.;* Staff 11 (MT) was hired 2/4/21, failed to complete pre-service orientation training prior to beginning their job duties in the following areas: - Specific aspects of dementia car and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;- Environmental factors that are important to a resident's well-being;- Family support and the role the family may have in the care of the resident;- How to recognize behaviors that indicate a change in the resident's condition and report behaviors that required on-going assessment;- How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and- Use of supportive devices with restraining qualities in memory care communities.The need to ensure newly-hired direct care staff completed all orientation training and pre-service training prior to beginning their job duties and prior to working independently was reviewed with Staff 1 on 6/3/21 and 6/9/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 243, C 252, C 260, C 262, C 270, C 280, C 282, C 300, C 303, C 304 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 and C262.

Based on observation, interview and record review, it was determined the facility failed to provide a daily meal program for nutrition and hydration and failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 12 of 12 sampled residents (#s 1, 2, 4, 5, 6, 8, 9, 10, 11, 12, 13 and 14), whose service plans were reviewed. Residents 6, 8, 9, 10, 11, 12, 13 and 14 had significant to severe weight loss between 1/1/21 and 6/1/21. Findings include, but are not limited to:1. Resident's 1, 2, 4, 5, 6, 8, 9, 10, 11, 12, 13 and 14 current service plans were reviewed during survey. Each of the service plans lacked information, staff instructions related to individualized nutrition and hydration status and needs or were not followed by staff members providing care.2. Residents 1, 9, 10, 11, 12 were service planned to receive a puree diet. Residents 6, 8, 9, 10, 11, 12, 13 and 14 all required some form of meal assistance from staff. 3. Between 6/1/21 and 6/4/21, the following observations were made: * 6/3/21 at approximately 5:00 pm, Resident 8 spilled a full cup of his/her health shake on the dining room table. The staff who witnessed the spill did not offer the resident a replacement shake. The resident was service planned to receive between three and four shakes a day; and * 6/3/21 at approximately 5:10 pm puree diets served to residents were the consistency of water. At 5:30 pm surveyors requested the facility replace what was served with food that was the correct consistency. * The facility activity calendar had "Healthy Snacks" scheduled at 3:00 pm each day of the week. On 6/3/21, at approximately 3:15 pm, staff passed out Jello pudding cups and plastic spoons to residents sitting in the dining room and common room. Several residents had difficulty pulling the foil covering off the cups, one resident was observed chewing on the plastic spoon. On 6/4/21, staff passed out plastic wrapped cheese sticks. Several residents had difficulty removing the plastic from the cheese sticks and did not eat the snack. Staff did not assist residents with the snacks or provide any form of hydration. The failure of the facility to provide a daily meal program for nutrition and hydration and develop individualized nutrition and hydration plans resulted in unplanned weight loss for Residents 6, 8, 9, 10, 11, 12, 13 and 14. Refer to C 270, example 2 On 6/8/21 at 11:47 am, the survey team requested an immediate plan of correction to address the needs of the residents who had significant to severe weight loss. The plan was received and accepted at 6:52 pm and the situation was abated. The need to ensure the facility provided a daily meal program for nutrition and hydration, developed individualized nutrition and hydration plans for each resident, and staff followed the plans was discussed with Staff 1 (Memory Care Director), and Staff 13 (VP Memory Care) on 6/8/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in service plans for 3 of 3 sampled residents (#s 14, 16 and 17) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident's 14, 16 and 17's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 20 (Interim MCC Administrator), Staff 21 (VP operations), Staff 22 (RCC) and Staff 23 (Consultant RN) on 11/10/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2, 4 and 5's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and their service plans had been individualized in the following areas:* Residents' past and current interests; * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate in activities; and* Identified activities for behavior interventions.There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.On 6/8/21, the need to ensure residents were evaluated and an in individualized activity plan was developed for each resident was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 3 sampled residents (#s 14, 16 and 17) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Though Resident 14, 16 and 17's service plans offered some information about the resident's interests, the facility had not fully evaluated the resident's: * Current abilities and skills;* Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.The need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 20 (Interim MCC Administrator) and Staff 22 (RCC) on 11/10/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted 2 of 2 sampled residents (#s 4 and 5) and others in the community. Resident 4 experienced repeated physical altercations with other residents. Resident 5 exhibited physically aggressive behaviors. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in September 2020 with diagnoses including dementia and anxiety. Resident 4's most recent service plan dated 11/2/20, did not address the resident's behaviors such as physical altercations with other residents and effective resident specific interventions or approaches for staff to utilize for the behaviors. Resident progress notes, incident reports, and temporary service plans from 1/1/21 through 6/1/21 indicated the resident had at least six documented incidents of physical aggression on 1/9/21, 1/11/21, 2/13/21, 2/15/21, 3/15/21, and 5/19/21 towards other residents. Those incidents included physical aggression such as grabbing, slapping, hitting, and punching other residents. Temporary service plan interventions to address the behaviors included increased safety checks, redirection, and monitoring. There was no documented evidence the facility developed an individualized behavior plan to address behaviors.On 6/2/21, the surveyor witnessed Resident 4 walk up to an unsampled resident who was sitting in a chair, and call the other resident "liar". S/he then proceeded to run his/her walker into the other resident's legs, causing a approximately 1 x 1 inch bump and bruise to the other residents lower right calf. The unsampled resident stood up from the chair and push Resident 4 who then fell onto the floor. The facility's failure to evaluate and develop an individualized behavior plan to address Resident 4's negative behaviors resulted in continuation of the behaviors and injury to another resident. On 6/9/21, the need to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted the resident and others in the community as a result of unaddressed behaviors was discussed with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator). They acknowledged the findings.
2. Resident 5 was admitted to the memory care with diagnoses including dementia.Resident 5's 5/1/21 service plan described the resident as "cooperative" and stated the resident had "No behavior issues" "[Residents name] does not have current or history of disruptive, aggressive, verbal or socially inappropriate behavior."The following behaviors were documented in the resident's clinical record: * 5/1/21 "exit seeking all shift";* 5/2/21 "has been exit seeking and wandering the whole shift.";* 5/6/21 Was found on the assisted living patio, outside secured memory care unit; * 5/9/21 Was found outside away from facility with some policemen.";* 5/16/18 Became aggressive with care staff, swearing and raised his/her fist;* 5/18/21 Was found "by construction" outside of the secured memory care unit;* 5/29/21 Placed an alert for "pushing another resident up against entrance doors."; and* 5/30/21 "Resident opened and slammed the doors to the kitchenette and both entrances into the nursing area and flipped med tech and a caregiver off."Between 6/1/21 and 6/4/21 the following behaviors were observed: * Wandering up and down hallways entering other resident's rooms, wearing other residents clothing and sunglasses; * Frequently putting his/her arm inches from staff or other residents faces to show them his/her tattoos; * Pounding with his/her fists on exit doors and walls; * Approaching other residents swearing and yelling at them; and* Repeatedly approaching an unsampled female resident, standing directly in front of her, clenching his fists, then walking away. There was no documented evidence the facility had evaluated the resident's behaviors, including the elopements and physical aggression towards other residents, or updated the residents service plan. The facility failed to evaluate negative behaviors which could negatively impact the resident or others in the community. That put Resident 5 at risk for future elopement and other residents at risk of physical and emotional abuse. On 6/4/21 at 10:38 am, the survey team requested an immediate plan of correction address residents negative behaviors. At approximately 8:00 pm, the survey team received and accepted the plan and the situation was abated. The need to ensure resident behavioral symptoms which negatively impacted the resident other others and were included on the service plan was discussed with Staff 1 (Memory Care Director), Staff 2 (Resident Care Coordinator) and Staff 3 (Executive Director) on 6/4/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation areas was of sufficient weight and design to not aid in elopement. Findings include, but are not limited to:On 6/1/21, a tour of the facility courtyard revealed round metal patio tables and chairs which were easily moveable and not of sufficient weight or design to prevent elopementOn 6/1/21, the need to ensure furniture in the outdoor recreation areas was of sufficient weight and design to not aid in elopement was discussed with Staff 1 (Memory Care Director) and Staff 15 (Maintenance Director). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked outside their rooms. Findings include, but are not limited to:During the survey, observations of resident rooms revealed they were locked from the outside, preventing residents from entering their rooms without assistance from staff. Caregiving staff each carried a key which could open all residents' rooms. On 6/9/21, the need to ensure residents were not locked outside their rooms was discussed with with Staff 1 (Memory Care Director) and Staff 2 (Resident Care Coordinator). They acknowledged the findings.