Tanner Spring Memory Care

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).

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 02/04/26 10:55 am, the facility kitchen was observed to need cleaning in the following areas: * Flooring near exterior door and office – debris under storage racks; * Bulk bin lids in dry storage – food debris build up; * Walk in refrigerator floor – significant build up of food debris/spills; * Walk in refrigerator fans and ceiling – build up of black matter/dust; * Interior of microwave – food splatters; * Lower shelf below toaster – debris/spills; * Knife holders on wall – dust build up; * Spice shelf – debris build up; * Cover/lid on two door sandwich refrigerator – smears/hand prints; * Wall behind cooking equipment – grease drips/spills; *Wall next to grill – grease drips/spills; * Exterior oven doors – drips/greasy; * Shelf above cooking equipment – food debris/grease; * Side of stove -drips/spills; * Trays holding gallon jugs on lower shelf across from service line – spills/drips; * Dishwashing area – wall and caulking behind spray hose sink – black matter build up, garbage disposal – significant food splatters; drain – black/brown matter build up; * Wall surrounding mirror between dishwasher and three sink area – dust build up; * Ceiling vents and surrounding ceiling area throughout the kitchen – significant dust build up; * Commercial can opener – black matter/food debris build up, blade finish worn; and * Lower shelf below soda machine and coffee maker – spills/drips. Improper food storage included: * Dry storage – open bags of baking powder and marshmallows not dated, vanilla wafers not securely closed not dated; * Walk in refrigerator – shredded potatoes and carrots, fresh cut fruit not labeled or dated, open bag of pepperoni slices not dated and discolored; * Speed rack in walk in refrigerator – tray of uncovered individual servings of jello; * Walk in freezer – open bags of French fries, burger patties, breaded chicken fillets, sausage links, egg rolls, rolls not dated and/or securely closed; * Spice containers – lids not securely closed; and * Walk in freezer – cardboard boxes on floor. Other concerns included: * Lack of facial hair restraint; and * Garbage can near service line not covered when not actively being used. The areas of concern were observed and discussed with Staff 1 (Dining Services Director and discussed with Staff 2 (AL Designee) and Staff 3 (MC Director) on 02/04/26. The findings were acknowledged at 1:30 pm.

Tanner Spring Memory Care Survey Date 02/04/26 Compliance Date 03/01/26 C0240: Deficiency 1: Cleaning and Sanitation Issues Areas of Concern - Flooring near exterior door and office - Bulk bin lids in dry storage - Walk-in refrigerator floor, fans, and ceiling - Interior of microwave - Lower shelf below toaster - Knife holders on wall - Spice shelf - Other various areas Corrective Action - Conduct a thorough deep cleaning of all identified areas. - Establish a daily cleaning checklist for kitchen staff to ensure ongoing cleanliness. - Schedule a professional cleaning service for hard-to-reach areas (e.g., ceiling vents) if necessary. Responsible Person Dining Services Director and Executive Director Completion Date: 02/15/26 Monitoring Plan Daily inspections by the Dining Services Director for 30 days, followed by weekly evaluations for an additional 60 days with over site of the Executive Director Deficiency 2: Food Storage Violations Areas of Concern - Open bags of baking powder, marshmallows, and vanilla wafers - Untagged items in the walk-in refrigerator and freezer - Uncovered individual servings of jello Corrective Action - Implement a strict labeling and dating system for all food items. - Train kitchen staff on proper food storage techniques, including sealing and dating open items. - Conduct a full inventory check and reorganization of storage areas. Responsible Person Kitchen Manager Completion Date: 02/20/26 Monitoring Plan weekly audits of food storage practices with documentation of compliance. Deficiency 3: Lack of Personal Hygiene Compliance Areas of Concern - Lack of facial hair restraint - Garbage can near service line not covered Corrective Action - Enforce a policy requiring all kitchen staff to wear facial hair restraints and appropriate uniforms. - Ensure garbage cans are covered when not in use and train staff on proper waste disposal practices. ordered lids 2/5/26 for garbage cans identfied Responsible Person Dining Service Director and executive director Completion Date 02/5/26 Monitoring Plan: Monthly training sessions and evaluations for compliance, with a focus on personal hygiene practices. Summary of Monitoring and Evaluation -Daily Inspections Conducted by the Dining Services Director for cleanliness. weekly Audits Checked by the Kitchen Manager for food storage compliance. Monthly Training Evaluations Administered by the Dining Service Director to ensure adherence to hygiene policies. Documentation and Communication - Maintain records of all cleaning, training, and monitoring activities. - Communicate the corrective actions taken to all staff during a team meeting scheduled for February 18th, 2026.

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).

Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner and ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 03/04/26 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: * Walk in refrigerator fans and ceiling – build up of black matter/dust; * Interior of microwave – food splatters; * Wall behind cooking equipment – grease drips/spills; *Wall next to grill – grease drips/spills; * Exterior oven doors – drips/greasy; * Shelf above cooking equipment – food debris/grease; * Dishwashing area – wall and caulking behind spray hose sink – black matter build up, garbage disposal – significant food splatters; drain – black/brown matter build up; * Commercial can opener – black matter/food debris build up, blade finish worn; and * Lower shelf below soda machine and coffee maker – leaking plumbing with standing water. Observation of food storage included: * Dry storage – open bags of salt and graham cracker crumbs not dated; * Walk in refrigerator – open bag of hot dogs not dated and securely closed; * Walk in freezer – open bags of egg rolls, hashbrown patties and wedge potatoes not dated and securely closed; and * Walk in freezer – cardboard boxes on floor. Additional observations included: * Lack of facial hair restraint. The findings were observed and discussed with Staff 5 (Dining Room/Kitchen Manager) and Staff 4 (Executive Director) on 03/04/26. They acknowledged the findings at 11:40 am.

1. Sanitation Improvements - Immediate Actions: - Conduct a thorough deep cleaning of all identified areas, including: - Walk-in refrigerator fans and ceilings - Interior of microwaves - Walls behind cooking equipment and next to grills - Exterior oven doors - Shelves above cooking equipment - Dishwashing area and caulking behind sinks - Commercial can opener and lower shelves beneath soda machines and coffee makers - Responsible Person: Culinary Director - Completion Date: April 10, 2026 - Monitoring: Daily inspections for the first two weeks, then weekly for the next month. 2. Food Storage Compliance - Immediate Actions: - Review and organize all food storage areas: - Ensure all opened packages are dated and securely closed. - Remove any items stored improperly (e.g., cardboard boxes on the floor). - Implement a labeling system for all food items. - Responsible Person: Culinary Director - Completion Date: April 10, 2026 - Monitoring: Weekly audits by the Culinary Director for the next month, with random inspections thereafter. 3. Staff Training and Compliance - Immediate Actions: - Conduct a training session on proper kitchen sanitation practices and food safety protocols, including the importance of facial hair restraints. - Distribute written guidelines for all kitchen staff regarding hygiene and sanitation standards. - Ensure all staff members comply with wearing appropriate facial hair restraints during food preparation. - Responsible Person: Culinary Director - Completion Date: April 15, 2026 - Monitoring: Ongoing compliance checks during daily kitchen operations, with formal evaluations bi-weekly for the first two months. Evaluation Process - The Culinary Director will be responsible for monitoring the implementation of the above actions. A follow-up evaluation meeting will be scheduled on April 15, 2026, to review compliance with the corrective actions and make any necessary adjustments. - Documentation of all corrective actions, including cleaning schedules, training attendance, and food storage logs, will be maintained for review.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

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

Refer to C0240

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

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

Refer to C 240

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

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

Refer to C 240

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.

Abbreviations possibly used in this document:   ADL:               activities of daily living CBG:               capillary blood glucose or blood sugar CG:                 caregiver CS:                  Compliance Specialist cm:                  centimeter ED:                  Executive Director F:                     Fahrenheit HH:                 Home Health LPN:               Licensed Practical Nurse MT:                 Medication Tech MAR:              Medication Administration Record MCC:              Memory Care Community OT:                  Occupational Therapist PT:                  Physical Therapist PRN:               as needed RCC:               Resident Care Coordinator RN:                 Registered Nurse

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).

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.

C240 Community has removed screen to large mixer and cleaned the ares on and around the mixer including the dripps spills on the wall. DSM will monitor weekly task sheets that the dishwasher has maintained cleaning. Community has cleaned vents and and dust build up in and around ceiling vents in all the kitchen areas. Cleaning has been added to the maintance log for cleaning each month and will be reviewd by ED. Community has replaced caulking behind the spray hose and cleaned the area with bleach. dishwasher will maintain cleaning this area with bleach daily at end of shift with check off list. this will be folowed up by DSM and ED weekly. Walls and floors were all deep cleaned and will maintain free of dust, spills and drips by end of shifts and will be documented daily on a cleaning task list. This cleaning task will be monitored by DSM and ED weekly. All fod and drinks have been audited, labled and dated in th kitchen DSM will audit each week when completing envitory and maintain shelf life, labels and open /experire dates.

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).

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

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

See POC for 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.

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.

1. Tanner Spring will implement privacy screening for all shared apartments, ensuring views between residents are blocked by a mobile privacy screen or a permanent curtain. Locks will also be installed on all bathroom doors in memory care. 2. We will hold an in-service training on the resident bill of rights, which will cover issues related to residents' privacy and dignity. 3. The administrator will conduct weekly evaluations at random times to ensure that privacy screens are being used. 4. The Memory Care Administrator will be responsible for ensuring that these corrections are completed.

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.

1. The community will take the following actions to correct rule violations for the residents noted in the SOD: The community RN will reassess Resident 2, and the memory care administrator will create a service plan to reflect the current needs related to pain, skin, wounds, toileting, DME, and environment. Resident 4 passed away on July 26, 2024. The community RN will reassess Resident 1, and the MC administrator will create a service plan to reflect the current needs related to toileting assistance, fall interventions, and behavior interventions. The community RN will reassess Resident 3, and the MC Administrator will create a service plan to reflect the current needs related to nail assistance, DME, incontinence care, wound care, and hospice services. 2. Tanner Spring will review service plans, COC, and nursing support during the daily clinical meeting and update service plans when warranted. 3. Service plans will be evaluated and updated quarterly and as needed based on daily observations and discussions. 4. The community RN and Memory Care Administrator will be responsible for monitoring and completion.

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.

1. The community will take the following actions to correct rule violations for the residents noted in the SOD: Resident 4 passed away on July 26, 2024. The community RN will reassess Resident 3, and the MC administrator will initiate a service plan to reflect COC for wounds and dietary needs. Any relevant interventions will be noted. 2. Tanner Spring will complete an in-service training for all health services staff for COCs, and the MC administrator or designee will review the 24/72 hour report to see progress notes that require follow-up. 3. The COC process will be evaluated weekly during clinical meetings. 4. The Community RN and Memory Care Administrator will be responsible for monitoring and completing these tasks.

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; and 11/12/24- 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.

1. Resident 6 placed on alert for weight loss. Weekly weights and meal monitoring added to MAR for resident 6. PCP faxed regarding weight loss. TSP placed indicating resident's preferences of meals and snacks. Resident 6 added to Nursing significant change of condition monitoring due to weight loss. 2. All med techs will take oregon care partners course "understanding changes of condition for community based care facilities in Oregon." Med tech meetings will be held monthly for continued coaching and trainings including changes of condition, documentation, and when to notify LN of changes. 3. Progress notes will be reviewed daily by clinical team. weight review will be increased to weekly (previously was monthly) to capture declines earlier and place needed interventions when appropriate. 4. Administrator and facility nurse will be responsible for oversight and training of care team and reviewing progress notes daily and weights weekly.

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.

1. The community will take the following actions to correct rule violations for the residents noted in the SOD: Resident 4 passed away on July 26, 2024. The Community RN will assess Resident 2's wound and collaborate with the hospice nurse on wound management. 2. Tanner Spring will assign a licensed nurse to the memory care neighborhood for approximately 20 hours per week (8 hours devoted to RN), and they will be available at other times as needed. Tanner Spring has hired a second licensed nurse to augment the number of nursing hours within the community. 3. Tanner Spring will evaluate nursing hours during daily clinical meetings and weekly COC discussions and adjust hours as necessary. 4. The Memory Care Administrator and Community Executive Director will monitor that this change is being successfully implimented.

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.

1. The community will take the following actions to correct rule violations related to the use of the ABST as noted in the SOD: The community will update service plans for Resident 1, Resident 2, and Resident 3. Resident 4 is diseased. Each resident's ABST will be updated accordingly. 2. Tanner Spring will review updated ABST guidelines and adjust procedures for using the ABST to assess staffing needs. The review will include adjustments to the times associated with tasks. 3. The ABST will be updated every time a service plan is updated, including after quarterly evaluations and COCs are completed. 4. The Memory Care Administrator and Executive Director will oversee the ongoing use of the ABST for compliance.

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.

1. Actions taken to correct this rule violation are as follows: a. The facility will implement an annual training plan that includes fire drills to be completed alternating months of fire and life safety training and includes: * 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. The facility will implement an annual training plan that includes fire and life safety training to be completed on alternating months of fire drills. 2. System will be corrected so that violation will not happen again by; a. Comprehensive review of current fire drill forms to ensure they meet all required components. b. In servicing provided to administration and or designee conducting fire and life safety drills and education on process and documentation required. 3. Area needing correction will be evaluated monthly by the Administrator and Maintenance Director. 4. The Administrator, Maintenance Director and/or designee will be responsible to ensure corrections are completed and monitored.

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.

1. Action taken to correct this rule violation includes; a. All residents capable will be instructed on 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 by 9/23/24. Annual re-instruction will be completed in the third quarter of every year thereafter. 2. Fire & Life Safety Training for Residents: This system is being corrected to eliminate future violations as follows:     a. All new residents will be instructed of fire & life safety, within 24hrs of move-in, and reinstructed annually thereafter.     b. All resident fire and life safety documentation will be filed and kept on-site,     c. Facility Maintenance Director will keep an on-going spreadsheet of residents' admission dates, and dates of re-instruction     d. Facility Maintenance director will bring all fire & life safety training for residents, to  Quality Improvement Meetings for review. 3. This system will be evaluated as follows:     a. Within 24hrs of a new resident admission, &     b. Annually thereafter,     c. Facility administrator will review fire & life safety for residents, at least once monthly to ensure compliance. 4. The Administrator, Maintenance Director and/or designee will be responsible to ensure corrections are completed and monitored.

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.

1-4.  Please see POC response for 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.

1-4.  Please see POC response for 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.

1-4. Please refer to POC items C200, C361, C420, and C422.

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).

1. All staff members identified in the survey will complete pre-service training and any other identified training deficiencies immediately. 2. Tanner Spring will review all policies and procedures for conducting and recording training and audit employee files to ensure that staff member training is complete and up to date. 3. Training records will be audited semi-annually to communicate potential deficiencies well in advance of due dates. 4. The Memory Care Administrator and Community Executive Director will be responsible for completing and monitoring these actions.

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.

1-4. Please refer to POC items C260, C270, and C280.

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.

Please see POC for 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.

1. Tanner Spring will reevaluate Resident 2 and Resident 3 and create an individualized nutrition and hydration plan as part of their service plan. This plan will address issues like the need for using adapted eating utensils and creating visual contrasts during meals. 2. All service plans will be audited for individualized nutrition and hydration needs and will be updated as required. 3. Nutrition and hydration plans will be re-evaluated during quarterly evaluations or when there is a COC. 4. Memory Care Administrator or designee.

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.

1. Tanner Spring will reevaluate Resident 1, Resident 2, and Resident 3 and create an individualized activity plan as part of their service plan. This plan will address their current abilities and skills, emotional and social needs, past and current interests, physical abilities and limitations, and activities needed for behavioral interventions. Resident Four passed away on July 26. 2. All service plans will be audited for individualized activity plans and will be updated as required. 3. Activity plans will be re-evaluated during quarterly evaluations or when there is a COC. 4. The Memory Care Administrator and Life Enrichment Director will be responsible for monitoring activity plan updates.

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.

Please see POC for C270

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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the 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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the 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 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 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 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 MTs Swing: 2 CGs, 1 MT Noc: 2 CGs, 1 MT A 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.

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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on 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 MTs Swing: three CG and one MT Noc: one CG and one MT These 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 MTs Swing: three CG and one MT Noc: one CG and one MT A 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.

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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day