Table Rock Memory Care Community

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 OAR 333-150-000. Findings include, but are not limited to: On 05/19/26, between 10:30 am and 01:30 pm, the facility kitchen was observed, and the following was identified: 1. Areas in need of cleaning in Main Kitchen: *Hood vents, convection ovens, stovetop, grill, floor drains – carbon build-up and/or food spills in and around appliances; * Ice machine – white/black matter inside and dusty screen; * Refrigerator – dusty external vent; * Walk-in refrigerator – white matter on fan and shelves; and * Stainless frying pans – carbon build-up inside. 1a. Cleaning in Cottage B Kitchenette: * Refrigerator– food spills; and * Freezer – ice build-up. 1b. Cleaning in Cottage C Kitchenette: * Refrigerator –has food spills. 1c. Cleaning in Cottage D Kitchenette: * Refrigerator – has food spills; and * Freezer – has ice build-up. 2. Areas in need of repair/maintenance in Main Kitchen: * Steamer – leaking on the floor; * Handwashing sink – leaking faucet; inconsistent water temperatures; * Frying pans – Teflon surface that was scored; * Dish machine – missing data plate; * Cutting board on steamtable and in prep area – heavily scored, stained, non-cleanable; * Refrigerator – food stored in unsealed containers; * Pantry – dry goods not in rodent proof containers; * Exit door to outside from kitchen– has missing seal at bottom corner; and * Garbage – without lid. 2a. Repair/Maintenance in Cottage C: * Garbage – without lid. 3. Sanitation in Main Kitchen: * Chemical PH strips – test strips were expired; and * Leftovers – were returned to kitchen and placed into refrigerator after being in the cottage dining rooms. 3a. Sanitation Cottage B: * Hand Sinks – not dedicated. 3b. Sanitation Cottage C: * Hand Sinks – not dedicated; and * Refrigerator - above required temperature (discarded food). 3c. Sanitation in Cottage D: * Supplement – undated after thawing. The areas of concern were observed and/or discussed with Staff 2 (Wellness Coordinator/PIC) and Staff 4 (Cook) at approximately 01:30 pm on 05/19/26. Staff acknowledged the findings.

Areas in need of cleaning: Hood Vent: Professional cleaning schedue 6/8/26 and then every 6 months. Dietary Manager has on an every 2 week deep clean schedule that she is monitoring with dietary cleaning staff. Stove top: Dietary manager ordered alternate cleaning products to ensure proper cleaning. Completed 6/5/26. Staff to clean daily and Dietary Manger has on a weekly deep cleaning schedule that she is monitoring with dietary cleaning staff. Convection Oven: Cleaning completed on 6/4/26. Dietary Manager has on a weekly cleaning schedule that she is monitoring with dietary cleaning staff. Grill: Dietary manager ordered alternate cleaning products to ensure proper cleaning. Completed 6/5/26. Dietary Manager has on weekly cleaning schedule that she is monitoring with dietary cleaning staff. Floor Drains: Completed 6/5/26. Dietary Manager has on weekly cleaning schedule that she is monitoring with dietary cleaning staff. Carbon build up and/or food spills around appliances: Cleaning completed 6/5/26. On daily cleaning schedule with dietary staff and Dietary Manager has on weekly deep cleaning schedule that she is monitoring with dietary staff. Ice Machine: Applied Refridgeration deep cleaned and serviced on 5/21/26. They complted training with Dietary Manager on how to clean and care for ice-machine. On monthly deep cleaning schedule with Dietary Manager. Refrigerator - dustany external vent: Cleaned 5/21/26. On weekly cleaning schedule for dietary staff. Dietary Manager monitoring weekly. Walk-in refrigerator - white matter on fan and shelves: All shelving/fans cleaned as of 6/5/26. On cleaning schedule to be wiped down weekly and shelving to be taken out monthly to be pressure washed. On Dietary Manager has on weekly/monthly cleaning schedule that she is monitoring with dietary cleaning staff. Stainless Frying Pans - carbon build-up inside: New pans ordered 6/4/26. Dietary Manager will monitor monthly to ensure they are in proper condition and order new as needed. Teflon Fying Pans - surface that was scored: New pans ordered 6/4/26. Dietary Manager will monitor monthly to ensure they are in proper condition and order new as needed. Dish Machine - missing data plate: Ordered 5/30/26. Awaiting delivery. Second plate ordered in event it is needed. Dietary Manager has on mothly schedule to observe for placement. Handwashing sink - leaking faucet; inconsisten water tempatures: Plummer came 5/30/26 and ordered new parts. To be installed 6/9/26. Dietary Manager to monitor monthly for leaks and Maintenance Director to do monthly water temp monitoring. Steamer - leaking on the floor: Interstate Appliance scheduled for repair on 6/15/26. Dietary Manager will report any further issues immediately to Maintenace Supervisor for repair or to schedule repair. Cutting board on steamtable and in prep area - heavily scored, stained, non-cleanable: After investigation, found where to order new cutting board. Ordering from Curtis Restaurant Repair on 6/8/26. ED will look at quarterly with Dietary Manager to address any further concerns. Refrigerator - Food stored in unsealed containers: Dietary staff inserviced on proper storage on 5/21/26. Dietary Manager to do daily walk throughs on her work days to monitor for inproper storage and do on the spot training. Pantry - dry goods not in rodent proof containers: Items moved into proper containers on 5/21/26. Containers ordered 6/4/26 for the remainder of items that community did not have containers for. Dietary Manager to complete weekly audits for compliance and needed staff training. Exit door to outside from kitchen - missing seal at bottom of container: 6/4/26 seal was repaired by Maintenance Director. Dietary Manager will monitor monthly for proper repair. Gargabe: without lid: Lids now on all garbages. Manager check during daily rounding. Scheduled for all staff inservice on 6/18/26 to reinforce requirement for lids. Chemical PH strips - test strips were expired: Replace on5/21/26. Dietary Manager will monitor mothly to ensure within date. Leftovers were returned to kitchen and placed into refrigerator after being in the cottage dining rooms: All staff inserviced 5/20/26 to dispose of items. Items no longer being refrigerated. Daily continued monitoring from dietary staff for compliance. Cottage B, C,D: Hand sinks not dedicated: 6/4/26 all staff inserviced to utilize beverage tubs that beverages are delivered in vs. transfering beverages and ice to sink. Sinks are now dedicated solely to handwashing and dirty dishes. Managers to monitor daily during rounding to ensure compliance. Garbages - without lids: Lids now on all garbages. Managers to check during daily rounding. Scheduled for all staff inservice on 6/18/26 to reinforce requirement for lids. Refrigerators - food spills: All refrigerators clean as of 5/21/26. On night shift caregiver cleaning schedules. Maintenance to monitor weekly for compliance. Freezers - ice build up: All freezers defrosted 5/21/26. Maintenance Director to monitor weekly and defrost as needed. Fridge Cottage C - above required tempature. Fridge replaced 5/28/26. Daily temps taken. RCC's to review weekly for compliance. Cottage D supplement - undated after thawing. Med Tech's inserviced that supplements need to be dated upon opening on 5/21/26. LPN will re-inservice on 6/18/26 at Med Tech meeting. RCC will audit weekly for compliance.

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 C240.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs;

Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that was based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to: During the survey, 06/30/25 through 07/02/25, observations of the memory care units showed minimal group activities. The television was on throughout the day. One to two residents were observed to color intermittently during the observations. One resident played a game with staff in Cottage C. Additional residents were observed sleeping in their chairs, in their rooms or wandering the common area, dining room and halls, throughout the rest of the day. Care staff were not observed to initiate any additional large or small group activities or offer the residents other things to do. Interviews were conducted on 07/01/25 with Staff 9 (MT) and Staff 17 (CG). Staff 17 indicated she was in to help with activities today. She normally was a caregiver, but activity staff was out sick. Staff 9 indicated the facility normally had an activity staff Monday through Friday that worked in all three units. Activities were done in each unit and some activities like bingo would be done in one cottage and interested residents would go to the one house. The residents who remained in their own cottages would have a group activity done by staff. The need to ensure a daily activity program was provided for residents to address their mental, physical, and psychosocial needs was reviewed with Staff 1 (ED) and Staff 3 (Resident Care Manager) on 07/02/25. Staff 1 stated they had extra staff in to cover for activities this week. She was unsure why activities were lacking. The staff acknowledged the findings.

1. Community has daily, scheduled program of social/recreational activities planned and posted as "Activities Calendar" ongoing. Community identified 17 residents that do not often prefer or routinely participate in activites, community developed new "Moments Together." program to engage them. Community has additionally implemented individual totes in B, C, D Cottages with pre-planned, prepared activities for care staff to resource in down times or as needed. Community hired an Activities Assistant for weekends and as needed to ensure 7 days per week, activity engagement for residents. 2. Community will work with Activities Director and Assitant to ensure that daily activities program schedule is being met, Administrator and IDT will ensure activities are occuring through performing spot checks and random audits. Administrator will meet with Activities Director weekly for 1:1 to review and ensure schedule effectiveness and new program implementatation is effective. 3. Weekly. 4. Activities Director and Adminstrator.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs;

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans reflected the residents’ needs and preferences, gave clear direction to staff with a written description of who should provide the services and what, when, how, and how often the services should be provided, handwritten changes were dated and initialed, and were implemented for 4 of 5 sampled residents (#s 1, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 09/2021 with diagnoses including Alzheimer’s disease and depression. The resident's service plan available to staff, dated 04/14/25, Resident 3’s service plan located in the facility’s electronic system, also dated 04/14/25, and progress notes, dated 04/05/25 through 06/25/25, were reviewed. Staff were interviewed and Resident 3 was observed. The service plan available to staff lacked clear direction to staff which included a written description of who should provide the services and what, when, how, and how often the services should be provided, and/or was not being implemented in the following areas: * Resident-specific direction to staff on how to get the best participation with meal assistance; * Cleaning under arms and left hand, then placing a cloth when caring for the resident's contractures and reducing the risk of skin issues; * Hospice providing scheduled showers and facility staff providing PRN bed baths; * One to two staff members needed for repositioning, bed baths, dressing, and incontinence care; * Preference of having the apartment door open; * Checking on the resident at least three times an hour, and repositioning every two hours; * Pureed foods; * Thin liquids with the use of a straw; * What to read to Resident 3 and where the reading material was located; * How to ensure the resident got to listen to his/her calming music of choice; * How Resident 3 showed signs or symptoms of depression; * Use of sertraline for depression; * Resident-centered ways s/he communicates his/her needs (e.g., fidgeting when wanting to get up, holding arms close to the body when cold, whimpering when s/he is uncomfortable, etc.); * The use of a high back, tilt-in-space wheelchair with footrests; and * No longer requiring a soft brace on the dependent arm. There were handwritten changes on the service plan available to staff pertaining to the number of staff needed for dressing, grooming, and oral hygiene that were not dated and initialed. The service plan located in the facility’s electronic system was more reflective of the resident’s care needs but was not available to caregivers, as they did not have access to the electronic system. The need to ensure service plans provided clear caregiving instruction, handwritten changes were dated and initialed, and the service plan was being implemented was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), and Staff 25 (RN) on 07/02/25 at 4:58 pm. They acknowledged the findings. 2. Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan, dated 06/06/25, revealed the service plan was not reflective of the resident's current care needs and preferences, did not provide clear direction to staff, and/or was not consistently implemented in the following areas: * Prescribed diet of pureed textures; * Food preferences reflective of the resident’s pureed diet; * Settings related to the resident’s air mattress; * Location of toileting assistance; * Shower days; and * Shaving. The need to ensure resident service plans were reflective of current care needs and preferences, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings. 3. Resident 1 moved into the facility in 05/2022 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and review of the service plan, dated 05/22/25, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented, and/or did not provide clear direction to staff in the following areas: * Gait belt use; * Fall mat placement; * Snacks and hydration throughout the day; * Activities; and * Behaviors, including verbal aggression. The need to ensure resident service plans were reflective of current care needs, were consistently implemented, and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (Resident Care Manager) on 07/02/25. They acknowledged the findings. 4. Resident 5 moved into the facility in 11/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan, dated 05/22/25, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented, and/or did not provide clear direction to staff in the following areas: * Hallucinations, anxiety about the “man upstairs,” and fear of poisoned food/fluids; * Activities; * Crying and yelling; * Agitation with roommate and claims of theft; * Toileting and incontinence care; and * Safety interventions, including non-skid footwear. The need to ensure resident service plans were reflective of current care needs, were consistently implemented, and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (Resident Care Manager) on 07/02/25. They acknowledged the findings.

1. Service plans for residents 1, 3, 4, 5 have been updated with required information to ensure that resident needs and preferences clear instructions for staff for providing resident specific care. 2. Administrator will work with clinical team to ensure all resident service plans are detailed with resident specific information and provide clear instructions for staff to ensure resident preferences are honored. Administrator is working with families/POA/Guardians to obtain more resident specific information to make the service plans more individualized 3. Daily, weekly, monthly, quarterly. 4. Administrator.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

Based on interview and record review, it was determined the facility failed to ensure residents who had changes of condition had resident-specific instructions or interventions developed and communicated to staff, and weekly progress documented until resolution for 3 of 5 sampled residents (#s 1, 4, and 5) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 05/2022 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and review of the resident's 05/22/25 service plan, 04/01/25 through 06/29/25 Interim Service Plans, progress notes, dated 04/07/25 through 06/30/25, physician communications, and incident investigations were completed. Multiple observations of the resident were made between 06/30/25 and 07/02/25. The resident was observed while in bed, in the common areas, and in the dining room at meals. The resident moved around the facility in his/her wheelchair and in/out of other residents’ apartments. The resident experienced multiple short-term changes without resident-specific directions communicated to staff and/or progress noted at least weekly until resolution in the following areas: * Behaviors, including resident-to-resident altercations; * Medication changes; * Skin injury; * Falls and safety interventions; and * Cough/sickness. The need to ensure short-term changes of condition had documentation of resident-specific directions communicated to staff and weekly progress was noted through resolution was discussed with Staff 1 (ED) and Staff 3 (Resident Care Manager) on 07/02/25. The staff acknowledged the findings. 2. Resident 5 moved into the facility in 11/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 05/22/25 service plan, 04/03/25 through 06/29/25 Interim Service Plans, progress notes, dated 04/01/25 through 06/30/25, physician communications, and incident investigations were completed. Multiple observations of the resident were made between 06/30/25 and 07/02/25. The resident was observed while in bed, in the common areas, and in the dining room at meals. The resident moved around the facility with his/her walker and stand-by assistance from staff. The resident moved very slowly but appeared steady on his/her feet. The resident experienced multiple short-term changes without resident-specific directions communicated to staff and/or progress noted at least weekly until resolution in the following areas: * Falls and safety interventions; * Foot pain; * Resident-to-resident altercations; * Anxiety and paranoia around roommate and potential theft; and * Left hip/thigh pain, increases in pain complaints, and hip x-ray. The need to ensure short-term changes of condition had documentation of resident-specific directions communicated to staff and weekly progress was noted through resolution was discussed with Staff 1 (ED) and Staff 3 (Resident Care Manager) on 07/02/25. The staff acknowledged the findings. 3. Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 06/06/25 service plan, 04/02/25 through 06/29/25 Interim Service Plans, 04/01/25 through 06/29/25 progress notes, and corresponding incident investigations were completed. The facility failed to determine resident-specific actions or interventions needed for the resident, communicate the actions or interventions to staff on each shift, and/or document weekly progress until the condition resolved for the following short-term changes of condition: * 05/12/25 – Cut to the nose; * 05/23/25 – Change to morphine dosing (for pain); * 05/23/25 – New Debrox treatment for ear wax; * 05/30/25 – Fall; * 05/30/25 – Abrasion to forehead; * 05/30/25 – Increased lorazepam dosing (for anxiety); * 05/30/25 – New acetaminophen (for pain); * 05/30/25 – New morphine (for pain); * 05/31/25 – New haloperidol (for anxiety); * 06/04/25 – New cyclobenzaprine (muscle relaxant); * 06/27/25 – Fall; and * 06/27/25 – Skin tear. The need to ensure the facility determined and documented what resident-specific actions or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored the changes of condition at least weekly through resolution was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. For residents 1,4, and 5 the RN assessed each resident, a review was completed of progress notes for changes of condition and alert charting was completed through resolution. Changes/updates were made as needed. 2. Community holds a clinical meeting each business day that reviews progress notes, alert charting notes, and TSPs. Any changes of condition will be reviewed for all required elements and determine need for change of condition monitoring including through resolution. Follow up action to be implemented as appropriate at that time. 3. Daily, weekly. 4. The Licensed Nurse and Administrator.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

Based on observation and interview, it was determined the facility failed to maintain effective infection prevention and control protocols for multiple sampled and unsampled residents related to dining services and for 2 of 3 sampled residents (#s 3 and 4) dependent on staff for ADL care. Findings include, but are not limited to: 1. Lunch service was observed in Cottages B and C on 06/30/25 - 07/02/25. a. Staff were observed serving meals and beverages, touching residents ,and assisting residents with feeding without changing their gloves or performing hand hygiene. b. Direct care staff were observed serving food to residents without donning a protective barrier over potentially contaminated clothing. The need to ensure the facility maintained infection prevention and control protocols to provide a safe, sanitary, and comfortable environment during meal service was reviewed on 07/03/25 at 10:24 am with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN). They acknowledged the findings. 2. Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. Observations of the resident and interviews with staff from 06/30/25 through 07/03/25 revealed Resident 4 relied on staff for incontinence care. On 07/01/25 at 1:18 pm, Staff 15 (CG) and Staff 17 (CG) donned gloves to provide ADL care for Resident 4. The resident's incontinence brief was unfastened, the resident was physically repositioned to determine whether his/her brief was dry, s/he was determined to be clean and dry, and then his/her brief was re-fastened. Staff 15 and Staff 17 doffed their soiled gloves and donned new gloves without completing hand hygiene between tasks. Then Staff 15 and 17 assisted the resident by adjusting the bed, pillows, and blankets. Following cares, Staff 15 and 17 doffed the soiled gloves. Staff 17 failed to complete hand hygiene prior to leaving the room and then the cottage. The need to establish and maintain effective infection prevention and control protocols while performing ADL care was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings. 3. Resident 3 moved into the facility in 09/2021 with diagnoses including Alzheimer’s disease. Observations of the resident and interviews with staff from 06/30/25 through 07/03/25 revealed the resident relied on staff for incontinence care. On 07/01/25 at 10:27 am, Staff 19 (CG) and Staff 29 (CG) donned gloves to provide ADL care for Resident 3. The resident's incontinence brief was unfastened and removed, staff turned Resident 3, wiped his/her bottom, applied barrier cream, put a clean brief on, changed the resident’s clothes, and got the resident ready for a hoyer lift transfer. Resident 3’s wheelchair handles, the hoyer including the sling and controls, a blanket, and the resident’s hair were all touched without doffing gloves and without performing hand hygiene. Following cares, Staff 19 and 29 doffed the soiled gloves and both staff members failed to complete hand hygiene prior to leaving Resident 3’s apartment. The need to establish and maintain effective infection prevention and control protocols while performing ADL care was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), and Staff 25 (RN) on 07/02/25 at 4:58 pm. They acknowledged the findings.

1. Staff were provided infection control education during the survey on the need for aprons and hand hygeine during meal service and the need for hand hygeine and the use of gloves during personal care. 2.Staff Training was provided on 07/30/25 that covered the importance of hand hygiene, how to perform assisted dining with dignity and staff apron use. Community purchased new aprons for each cottage on 7/15/25. The management team will monitor compliance through observations and audits during meal times and when staff are providing personal care. A new observation checklist was developed. 3.Weekly, monthly. 4. Administrator.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. The resident's physician orders, the Controlled Substance Disposition logs, and the MAR, dated 06/01/25 through 06/29/25, were reviewed. Resident 4 had the following physician’s orders: * Lorazepam 1 mg – one tablet by mouth every six hours for anxiety; and * Lorazepam 1 mg – one tablet by mouth every two hours as needed for anxiety. a. The following doses of scheduled lorazepam were documented in the MAR but were not documented in the Controlled Substance Disposition log: * 06/04/25 – 8:00 am dose; * 06/11/25 – 8:00 am dose; * 06/13/25 – 2:00 am dose; * 06/15/25 – 2:00 pm dose; * 06/27/25 – 8:00 pm dose; and * 06/28/25 – 2:00 am dose. b. The following doses of scheduled lorazepam were documented in the Controlled Substance Disposition log but not documented in the MAR: * 06/12/25 – 8:00 am and 2:00 pm doses; and * 06/27/25 – 2:00 pm dose. c. The following doses of scheduled lorazepam were not documented in either the MAR or the Controlled Substance Disposition log: * 06/11/25 – 8:00 pm dose; and * 06/12/25 – 2:00 am dose. d. The following dose of PRN lorazepam was not documented in the MAR: * 06/27/25 – 4:30 pm dose. The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. Resident #4 no longer resides in the facility. His MAR and controlled substance logs were reviewed for discepancies at the time of the survey. 2. Medication Techs were educated on the controlled substance protocol on 7/23 and 7/24. Administrator and clinical team will review controlled substance count records against the MAR administration and missed medication reporting with followup. The Missed Medication report will be reviewed daily during clinical meeting for any issues, with follow up as needed. A controlled substance record and count review will occur weekly. An audit tool was developed for use during observation of counts. 3. Weekly. 4. Licensed Nurse and Administrator.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, including medication-specific instructions, and provided resident-specific parameters and instructions for PRN medications for 3 of 4 sampled residents (#s 2, 3, and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the MCC in 03/2022 with diagnoses including frontotemporal dementia and anxiety disorder. Resident 2's current physician's orders, MAR, dated 06/01/25 through 06/30/25, and progress notes, dated 05/01/25 through 06/30/25, were reviewed. The following medications lacked medication-specific instruction: * Quetiapine (for bipolar disorder/ mood) 100 mg tablet did not have side effects listed; and * Gabapentin (for pain) 100 mg capsule did not specify the route of delivery. The need to ensure MARs were accurate and provided medication-specific instruction was reviewed on 07/03/25 at 10:24 am with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN). They acknowledged the findings. 2. Resident 3 moved into the facility in 09/2021 with diagnoses including Alzheimer’s disease. The resident’s current physician’s orders, MAR, dated 06/01/25 through 06/30/25, and progress notes, dated 04/05/25 through 06/25/25, were reviewed. The following inaccuracies were identified: a. There was no documentation if the resident's scheduled lactulose (for bowel management) was administered on 06/20/25 or his/her scheduled health shake (for a nutritional supplement) was provided on 06/02/25 at 5:00 pm, as the MAR was blank on those dates. b. There were blanks relating to monitoring Resident 3's bowel movements six times from 06/01/25 through 06/30/25. In addition, staff documented "NA [not applicable]" 21 times. The options for staff to document were: "S = Small," "M = Medium," and "L = Large." "NA" was not an option provided for staff to document relating to monitoring the resident's bowels. c. Staff were directed to document a number relating to the resident's pain prior to administrating scheduled acetaminophen. Staff documented "NA" six times instead of a number. d. Staff were directed to monitor the percentage of meal consumed by the resident. There were seven blanks in which staff did not document anything between 06/02/25 and 06/25/25. e. Resident 3 had two PRN medications prescribed for pain. There was no direction to staff on which sequential order to administer the medication. f. The resident had three PRN medications prescribed for constipation. Although the Milk of Magnesia directed staff to administer the medication first, and directed staff to administer two doses, there was no direction on how much time to allow between the first and second dose. In addition, the other two bowel medications lacked the sequential order for administration if there was no result from the two Milk of Magnesia doses. The need to ensure MARs were accurate, and included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), and Staff 25 (RN) on 07/02/25 at 4:58 pm. They acknowledged the findings. 3. Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. Resident 4's physician orders and MAR, dated 06/01/25 through 06/29/25, were reviewed during survey. The following PRN pain medications lacked resident-specific parameters or instructions to staff: * Acetaminophen 325 mg tablet; * Acetaminophen 650 mg suppository; and * Morphine sulfate 0.75 ml by mouth or sublingually. During an interview with Staff 14 (MT) on 07/01/25 at 2:54 pm, she confirmed the PRN pain medications lacked resident-specific parameters or instructions for unlicensed staff. The need to ensure PRN medications included resident-specific parameters and instructions to unlicensed staff was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. Residents 2,3,4 will have orders reviewed for accuracy, completeness, resident-specific instructions, and parameters with updates to orders as needed. 2. An audit will be conducted of resident records for accuracy, instructions, and parameters of medication orders. Any noted issues will be addressed when found. Med techs will be educated on medication administration and documentation.The missed medication report will be reviewed during daily clinical meeting to identify missed charting. Follow up will be completed. Community has implemented a triple check process for orders to assure accuracy, instructions and parameters are in place. 3. Daily, weekly. 4. Licensed Nurse and Administrator.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

Based on interview and record review, it was determined the facility failed to ensure PRN medications that were given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective prior to their administration for 2 of 4 sampled residents (#s 2 and 4) who were prescribed psychotropic medications. Findings include, but are not limited to: 1. Resident 2 moved into the MCC in 03/2022 with diagnoses including frontotemporal dementia and anxiety disorder. The resident's 06/01/25 through 06/30/25 MAR and prescriber orders were reviewed, and staff were interviewed. Resident 2 had orders for clonazepam 0.5 mg tablet: take one tablet by mouth every eight hours as needed for anxiety. The MAR indicated the PRN medication was administered on 06/01/25, 06/11/25, and 06/28/25. The resident's record lacked evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication. The record also lacked instruction to staff on when to contact a health professional regarding side effects. Staff 9 (MT) was interviewed on 07/02/25 at 11:20 am, and Resident 2’s MAR was reviewed. She acknowledged not all MTs have documented non-pharmaceutical interventions attempted prior to administration of PRN psychotropic medication. The need to document attempted and ineffective non-pharmacological interventions prior to administering PRN psychotropic medications was reviewed on 07/03/25 at 10:24 am with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN). They acknowledged the findings. 2. Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. The resident's 06/01/25 through 06/29/25 MAR and prescriber orders were reviewed, and caregivers were interviewed. a. The resident’s PRN haloperidol and lorazepam medications, both used for agitation and anxiety, lacked resident-specific parameters or instructions to staff. This was confirmed during an interview with Staff 11 (MT) on 07/02/25 at 11:48 am. b. Resident 4 had a physician order for lorazepam 1.0 mg - take one tablet by mouth every two hours for anxiety. The MAR indicated the resident received the PRN medication seven times between 06/03/25 and 06/23/25. The resident's record lacked evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication in six of the seven administrations. Resident 4 also had a physician order for haloperidol 0.5 mg – take one tablet by mouth/sublingual every four hours as needed for agitation/nausea. The MAR indicated the resident received the PRN medication once on 06/13/25. The resident’s record lacked evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication. On 07/03/25 at 8:44 am, Staff 1 (ED) confirmed non-pharmacological interventions attempted prior to the administration of the resident's PRN lorazepam or haloperidol were not documented in seven of the eight administrations reviewed. The need to ensure PRN medications administered to treat a resident’s behavior had resident-specific parameters and non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was reviewed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. Residents #2 and #4 have had their orders reviewed and updated with resident specific instructions and parameters. 2. Med techs have been educated on the need to document all non-pharm interventions prior to administering the PRN psychotripc meds. The revised triple check order protocol includes checking for staff instructions, resident specific interventions and parameters for administration. The LN will be the 3rd check in the process and will address any missing items. 3. Weekly. 4. Licensed Nurse and Administrator.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

Based on interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident who required two-person transfer assistance during the night shift. Findings include, but are not limited to the following: The acuity interview was completed on 06/30/25 at 1:21 pm with Staff 3 (Resident Care Manager) and Staff 9 (MT), and the “ABST Facility Entrance Questionnaire,” dated 06/30/25, was reviewed. The following was identified: * The MCC was home to 40 residents who resided in cottages B, C, and D. Cottage A was empty at the time of survey; * Four residents required two-person assist for transfers. At least one resident who required two-person assist resided in each of the three cottages in use; * Four residents required assistance with eating; * Eight residents had support for behavioral symptoms; and * Multiple other residents were reported to require high levels of caregiving assistance due to hospice status, need for one-person transfer assistance, need for frequent checks, and/or due to fall risk. The facility's posted staffing plan for each cottage and the staffing schedule from 06/23/25 through 06/29/25 were reviewed. The facility's posted staffing plan for the 6:00 pm to 6:00 am shift was as follows: * Cottage A – “Clear”; * Cottage B – one MT and one CG; * Cottage C – one MT and two CGs; and * Cottage D – one MT and one CG. The staffing plan was confirmed in an interview with Staff 1 (ED) on 07/01/25 at 3:55 pm. When Staff 1 was asked how the unscheduled needs of residents requiring two-person assist with transfers were met when staff took breaks, she acknowledged the facility was not currently in compliance. Staff 1 reported she would change the NOC schedule immediately. The facility lacked a sufficient number of overnight staff to meet the scheduled and unscheduled needs of the multiple residents who required the assist of two care staff for transfers, had high levels of care needs, had behaviors (including resident-to-resident altercations), and resided in three distinct cottages. On 07/01/25 at 4:46 pm, Staff 1 provided an updated schedule which included a float to relieve staff during their breaks for 07/01/25 and 07/02/25. From 07/03/25, the facility’s plan included staffing two CGs and one MT in each cottage. This updated schedule accounted for the scheduled and unscheduled needs of the residents. The need to have a sufficient number of staff in to meet all scheduled and unscheduled needs of residents on the overnight shift was discussed with Staff 1, Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. The community updated the schedule which includes a float to relieve staff during their breaks to meet scheduled and unscheduled needs of the residents. 2. The plan includes staffing two CGs and one MT in cottage C, one MT and 1 CG in the other two cottages during night shift. The Administrator completes ABST review multiple times per week with updates from daily clinical meeting and makes adjustments to the schedule as needed to meet resident care needs. 3. With changes and weekly. 4. Administrator.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

Based on observation, interview, and record review, it was determined the facility failed to accurately capture care time and care elements staff were providing to residents for 3 of 4 sampled residents (#s 2, 3, and 4). Findings include but are not limited to: Observations of Resident 2, 3, and 4 and interviews with direct care staff were conducted from 06/30/25 through 07/03/25. Review of Resident 2, 3, and 4’s current service plans and acuity-based staffing tool (ABST) evaluations were reviewed and revealed the residents’ allotted care minutes were not reflective of current needs in one or more of the 22 care areas of the ABST. The need to ensure the ABST accurately captured the care time and care elements for all residents in each of the 22 ADL areas was discussed with Staff 1, Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. Administrator reviewed the ABST for residents 2, 3 & 4 and after verifying residents care needs made neccesary adjustments in service plans and to the ABST to ensure congruency. The ABST was reviewed to include meal preparation and unscheduled resident needs. 2. Administrator is updating ABST multiple times per week after daily clinical meeting to ensure all resident change of condition or service plan updates are reflected. The staffing plan is adjusted by scheduler/Administrator to ensure the community is able to meet ongoing and changing resident needs. 3. With changes of condition and weekly. 4. Administrator.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills were conducted every other month which included all required components, and fire and life safety instruction was provided to staff on alternate months of fire drills. Findings include, but are not limited to: Facility fire drill records, dated 12/2024 through 06/2025, were reviewed and the following was identified: a. The fire drill documentation lacked one or more of the following required elements: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the fire drills; * Evacuation time; and * Number of residents evacuated. On 07/02/25 at 8:35 am, Staff 7 (Environmental Services Director) confirmed residents were not being evacuated. Due to the facility not evacuating residents during fire drills, there was no evidence alternate routes were used nor was there documentation on problems encountered. The facility would not be able to make the changes needed to ensure the evacuation standard was being met. b. The facility was not providing fire and life safety instruction to staff on alternating months from fire drills. The need to ensure unannounced fire drills were conducted every other month and included all required components, and fire and life safety instruction was provided to staff on alternate months of fire drills, was discussed with Staff 1 (ED) and Staff 7 on 07/02/25 at 8:40 am.

1. Community has updated the Fire Drill Evacuation checklist form to include all required componants for OFC life safety. 2. Training was provided to the Environmental Services Director and the Environmental Services assistant to ensure aknowledgment and understanding of Fire Drill Checklist additions. Additions on Community Fire Drill checklist: -Required listing of individuals who participated in the drill both staff and residents. * Including to note the residents who refused or failed to participate in the drill. -Required listing of the Escape route and/or alternate route that was used in evacuation drill. -Required listing of the time it takes to successfully complete the drill. -Required listing of the area in which the residents were evacuated to. Administrator and ESD developed semi-monthly training schedule for alternative, life safety training for the year. Training will include presentation/training for emergency procedures in the community. Training will be provided at monthly required staff meetings. 3. Monthly. 4. Administrator and Environmental Services Director.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and at least annually thereafter. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 07/01/25. The facility lacked documented evidence residents were instructed on general safety procedures, evacuation methods, and responsibilities within 24 hours of admission and annually. On 07/02/25 at 8:35 am, Staff 7 (Environmental Services Director) confirmed annual re-instruction had not been done with the residents. The need for residents to be instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (ED) and Staff 7 on 07/02/25 at 8:40 am. No additional information was provided.

1. Residents have received Fire and Life Safety (FLS) education. 2. Residents will be educated on Fire Life and Safety information anually and at the time of move in with resident and POA/Guardian. Administrator acknowledges that some residents may require individual training based on resident- specific needs. Administrator will review resident FLS education documentation for completeness 3. Monthly. 4. Environmental Services Director and Administrator.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure the interior of the building was maintained clean and in good repair. Findings include, but are not limited to: The facility was toured on 07/02/25 at 8:45 am with Staff 1 (ED) and Staff 7 (Environmental Services Director). The following was observed: Cottage B * Stains were observed on the carpet in the television area; * Vinyl was coming off from a black recliner located in the television area; * Multiple resident rooms were missing closet doors; * The laundry closet was observed to have holes in the wall, chipped paint, and there was missing flooring; * The cupboard underneath the kitchenette sink had brown- and rust-colored marks and the linoleum was pealing off; * The common use bathroom had areas in need of painting on the walls, door, and door jamb; * Dining room chairs were missing vinyl on the seats and/or the legs were scuffed with exposed wood; * Staff made comments about the dryer being very loud when in operation; * There was a door located across from room B7 that had a hole above the lever handle; and * Walls throughout the dining room were in need of painting due to chipped paint and/or gray scuff marks. Cottage C * Walls throughout the dining room, outside of the medication room, and in the laundry closet had chipped paint observed; * The laundry closet was observed to have flooring missing; * Multiple resident rooms were missing closet doors; * The skinny door and door jamb behind the kitchenette was observed to have drips down the left side by where the aprons were hanging; * The cupboard under the kitchenette's sink and the cupboard to the left of the stove had brown- and rust-colored stains observed; * Dining room chairs were missing vinyl on the seats and/or the legs were scuffed with exposed wood; * There were stains observed on the carpet in the television area; * The community bathroom had chipped paint observed on the walls and the inside of the door; and * The bathroom door had a hole above the lever handle. Cottage D * Multiple resident rooms were missing closet doors; * There was chipped paint observed on walls in the laundry closet, community bathroom, and dining room; * The windowsill on the outside of the medication room had chipped paint present; * The toilet in the community bathroom had rust coloring around the base on the floor; * The skinny door behind the kitchenette had chipped paint observed; * There was approximately two and a half inches of linoleum trim missing from the side of the countertop in the kitchenette, to the right of the refrigerator; * Doors and door jambs were observed to have gray or brown streaks or gouged/exposed wood with missing paint pertaining to room D3, the closet across the hall from room D7, the common use bathroom, where the "Sheets/Shower Towels" were stored, and the medication room; * Dining room chairs were missing vinyl on the seats and/or the legs were scuffed with exposed wood; and * The walls to the right of the laundry closet and in the dining room had scuffed and/or gouged wood observed. Common Area Outside the Cottages * All cottage doors had chipped paint both inside and outside present; * Both the kitchen’s entrance and exit doors had scuffs, scrapes, and chipped paint observed; and * The exit door that led into the reception area had chipped paint present. The above identified findings were acknowledged by Staff 1 and Staff 7 on 07/02/25.

1. Items in Cottage B have been addressed. -Carpet was shampooed 7/15/25 -Community plans to replace recliner in television area. -Community plans to repair or replace all missing closet doors. -Laundry closet was repaired and painted on 7/9/25, Community to get quotes on repair of laundry closet flooring. -Cupboard under the kitchen sink painted 7/9/25 community plans to replace the linoleum. -Common use bathroom painting planned for 8/6/25. -Community plans to replace dining room chairs. -Clothing dryer service, scheduled 8/7/25. -Community plans to repair any holes near door handles. -Community plans to complete dining wall painting. Items in Cottage C have been addressed. -Community has painted all white surfaces on 7/9/25 ; areas/walls of color are planned to be completed. -Laundry closet was painted on 7/9/25, Community to get quotes on repair of laundry closet flooring. -Community plans to repair or replace all missing closet doors. -Skinny kitchen door and jamb has been cleaned and painted on 7/9/25. -Cupboards in dining area and under sink painted 7/9/25, community plans to add linoleum. -Community plan to replace dining room chairs. -Carpet was shampooed on 7/15/25 -Common use bathroom painting planned for 8/6/25. -Community plans to repair holes above door handles. Items in Cottage D have been addressed. -Community plans to repair or replace all missing closet doors. -Laundry closet was painted on 7/9/25, community painted all the “White” areas on 7/9/25. All remaining areas of color and dining room to be painted. Common use bathroom painting planned for 8/6/25, medication room windowsill was painted on 7/9/25. -Community ordered supplies to remove the rust from near the toilet on the floor in the bathroom. -Skinny kitchen door has been cleaned and painted on 7/9/25. -Linoleum trim has been temporarily repaired until matching trim can be replaced. -Community has cleaned all doors and door jambs; white areas have been painted as of 7/9/25. All remaining doors, closets and trim to be repaired and painted. -Community plans to replace dining room chairs. -Community plan to paint and repair any scuffed/gouged wood. Common Areas Outside the Cottages -Community to paint all cottage doors both internally and externally. -Community plans to repair and paint both Kitchen entrance and exit doors on inside and outside. -Community plans to paint the exit doors to the lobby on both sides. 2. Environmental Services Director (ESD) will work with Administrator to develop a schedule for routine painting and repair. Community will use TELS to monitor community needed repairs. The Administrator and ESD will do weekly walk-throughs to identify needs. 3. Weekly. 4. Environmental Services Director and Administrator.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received services in a manner that protected dignity and respect. Findings include, but are not limited to: The following observations were made between 06/30/25 and 07/03/25: * Multiple staff members were observed referring to Resident 1 as “grandma”; * Multiple staff members were observed referring to Resident 3 as “momma”; * A staff member was observed referring to Resident 4 by an abbreviation of the resident’s name. The resident’s service plan, dated 06/06/25, did not indicate the resident preferred to be addressed as such; * A staff member was observed referring to Resident 4 and Resident 4’s roommate as “the boys”; * A staff member was observed referring to an unsampled resident as “sweetheart” and “sugar sugar”; and * Staff members were observed standing over residents as they assisted the residents with eating their meals. The need to ensure residents received services in a manner that protected dignity and respect was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 10:35 am. They acknowledged the findings.

1. Staff education regarding resident rights to dignity was provided to staff during survey. 2. Administrator provided training to all staff during 7/16/25 all staff meeting. Training provided was a reminder of resident rights, in depth training on privacy and dignity and the use of terms of endearment. Management will conduct walking rounds randomly throughout the day observing for continued care practices with dignity. Corrections to be made as they events occur. 3. Daily, weekly. 4. Administrator.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

Based on observation and interview, the facility failed to ensure each individual had privacy in his/her own unit for 2 of 3 sampled residents (#s 3 and 4) who required staff assistance for all ADLs. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 09/2021 with diagnoses including Alzheimer's disease. Observations of the resident and interviews with staff from 06/30/25 through 07/03/25 revealed the resident relied on staff for all ADLs and care. On 07/01/25 at 10:27 am, Staff 19 (CG) and Staff 29 (CG) were observed to provide incontinence care and dressing for Resident 3 in the resident's bed. The bed was located just below the windows in Resident 3's unit. The blinds were open, and the resident was visible to people passing by outside of the facility. Staff provided incontinence care and changed Resident 3's clothes with the blinds open. The need to ensure privacy in resident's units was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), and Staff 25 (RN) on 07/02/25 at 4:58 pm. They acknowledged the findings. 2. Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. Observations of the resident and interviews with staff from 06/30/25 through 07/03/25 revealed the resident relied on staff for all ADLs and care. On 07/01/25 at 1:18 pm, Staff 15 (CG) and Staff 17 (CG) were observed to provide incontinence care for Resident 4 while s/he remained in bed. Resident 4 shared the room with an unsampled resident. The room was observed to have a privacy curtain situated between the two beds. However, Staff 15 and Staff 17 failed to draw the privacy curtain when Resident 4 received incontinence care, and the unsampled resident remained in the room and in the line of sight of the ADL cares provided. The need to ensure privacy in residents’ units was discussed with Staff 1, Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. Staff education regarding resident rights to privacy was completed during survey. 2. Administrator provided staff training related to resident privacy on 7/16/25 during an all staff meeting. Adminstrator/designee will continue to provide training to staff to ensure that residents right to dignity and privacy are respected and upheld. Administrator/designee will be performing spot and random checks on each shift while care is being performed to ensure community ongoing compliance with the rule. 3. Weekly. 4. Administrator.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

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, interview, and record review, it was determined the facility failed to follow the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C295, C360, C362, C420, C422, and C513.

Refer to C295, C360, C362, C420, C422, C513

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.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, C302, C310, and C330.

Refer to C260, C270, C302, and C330.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

Based on observation, record review, and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: 1. Observations of the main facility kitchen, food storage areas, food preparation, and food service on 06/04/24 revealed splatters, spills, drips, and debris on:   - Can opener blade and casing; - Stand mixer; - Food Processor; - Carts; - Interior and exterior of the microwave; - Interior of drawers; - Walls throughout the kitchen; - Flooring and cove base throughout the kitchen; - Floor drains throughout the kitchen; - Interior of walk in freezer; - Food packages and containers in dry food storage area;, - Dishes and cookware stored on open shelving and racks; - Open stainless steel shelving and metal wire rack shelving; - Sides, front, knobs, and interior of the oven, grill, and range; - Range hood and grease trap; - Ceiling vents throughout the kitchen; - Front grate and interior of the ice machine; - Underneath shelving and equipment; - Floor of the walk in refrigerator and freezer; - Fan blades of the walk in refrigerator; - Dishwashing area including flooring, walls, and equipment; and - Walkie-Talkie. * Prepared foods were unlabeled and undated. * Packaged foods were not dated when opened. * Cutting boards were deeply scored and stained. * Scoops and cups were left in bulk bins of food. * Dish washing racks were stored on the floor. Visible debris was noted on the clean side of the dish machine. * A large hole was observed in the wall below the prep area table across from the walk in refrigerator. * The wall behind the ice cream freezer was damaged. * The laminate counter and cabinets in the back of the kitchen by the dishwashing area were damaged creating un-cleanable surfaces. * The hand washing sinks lacked splash guards and were located next to food preparation or storage areas. * Open garbage was observed full and stored next to a sink used for food preparation. * The storage shelf next to the ice machine was broken, spilling clean utensils and cookware onto the floor. * The back door to the kitchen was left propped open allowing for the entrance of pests. * A visibly dirty fan was stored in contact with clean cookware. * Dead ants were noted stuck in debris on the wall under the tray line shelf. * Staff were observed to not change gloves between tasks while preparing food and handling ready to eat foods. 2. Observations of the service kitchens on the individual units revealed: * Undated and unlabeled foods stored in the reach in refrigerators. * Un-covered plate of food was observed left in a microwave. * Interior of drawers had spills and debris. * Counters and cupboards were damaged. * There was no documented evidence of monitoring the temperatures of the mini-refrigerator/freezers. Temperatures were noted above 45 degrees.  The need to ensure foods were stored below 42 degrees discussed with Staff 1 (Assistant Executive Director). She agreed to dispose of protein based foods from the mini-fridges with low temperatures. The food handling and storage concerns, and the areas in need of cleaning and repair were reviewed with Staff 1. She acknowledged the findings.

1.) All identified splatters, spills, drips and debris on equipment, walls and flooring have been cleaned.  Unlabeled and undated food has been disposed of. Undated packaged foods have been disposed of. Scoops and cups have been removed from food bins. A large hole in wall has been patched. Laminate on counter repaired, splash guard placed next to handwashing sink.  Temperature logs have been placed in each cottage. 2.) New Executive Chef has created a cleaning schedule to be followed and Executive Director will round through kitchen daily to inspect. Executive Chef has provided education regarding labeled and dated foods. Education regarding scoops and cups in bins,cleaning schedule, open garbage, changing of gloves and temp logs 3.) Daily,Weekly 4.) Executive Chef, Maintenance Director and Executive Director

Based on observation, record review, and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The facility kitchen, food storage, and kitchenettes were toured with Staff 9 (Executive Chef) on 09/10/24. 1. Observations of the main facility kitchen, food storage areas, food preparation, and food service on 09/10/24 revealed splatters, spills, drips, and debris on:   - Flooring and cove base throughout the kitchen; - Food packages and containers in dry food storage area; - Dishes and cookware stored on open shelving and racks; and - Underneath shelving and equipment. * Prepared foods were unlabeled and undated. * Packaged foods were not dated when opened. * Scoops and cups were left in bulk bins of food. * Dish washing racks were stored on the floor. * The hand washing sinks lacked splash guards and were located next to food preparation or storage areas. * A visibly dirty fan was in operation in contact with clean cookware. * Dishes were stored on the floor. * Boxes were on the floor in the walk-in freezer. 2. Observations of the service kitchenettes on the individual units revealed: * Undated and unlabeled foods stored in the reach in refrigerators. * Un-covered plates of food were observed left in microwaves. * Interior of drawers had spills and debris. * Counters, cupboards, and drawer interiors were damaged. * There was no documented evidence of monitoring the temperatures of the mini-refrigerator/freezers. Temperatures were noted above 45 degrees. The food handling and storage concerns, and the areas in need of cleaning and repair were reviewed with Staff 8 (Executive Director). She acknowledged the findings.

1.) Flooring and cove base throughout kitchen has been cleaned, food packages and containers in dry stoarage area put up; Dishes and cookware stored on open shelving and racks have been covered; Underneath shelving and equipment have been cleaned; Prepared foods were thrown out as they were not labled and dated; Packaged foods not dated once opened thrown out; Scoops and cups left in bulk bins of food have been removed; Dish washing racks were removed from the floor; Hand washing sinks lacked splash guards and were located next to food preparation and storage unit stand mixer next to handwashing sink covered; Dirty fan by back door cleaned; Boxes on floor of walk in freezer removed from floor and placed on shelf.  In cottages undated and unlabled food from  refrigerators thown away; un-covered plates of food left in  microwave thrown away; Spills and debris in drawers cleaned; Damaged counters cupboards replaced; Documented evidence of monitoring refridgerator/fridge re-posted.  Education provided regarding temperatures over 45 degrees. 2.) New Executive Chef has created a cleaning schedule to be followed and Executive Director will round through kitchen daily to inspect. Executive Chef has provided education regarding labeled and dated foods. Education regarding scoops and cups in bins,cleaning schedule,  and temp logs 3.) Daily,Weekly 4.) Executive Chef, Maintenance Director and Executive

Based on observation, record review, and interview, it was determined the facility failed to ensure 5 of 8 sampled staff (# 2, 3, 4, 5, and 6) reviewed for food handlers certificates had current cards at the time of survey. Findings include, but are not limited to: On 06/04/24 the facility was asked to provide verification that staff who prepared and served food had current food handlers cards. There was no documented evidence Staff 2 (Dietary Staff) and Staff 3, 4, 5, and 6 (caregiving staff observed to plate and serve food ) had food handlers cards. Staff 1 (Assistant Executive Director) acknowledged the missing documentation.

1.) Audit completed of all staff who work in kitchen or serve food to ensure food handlers cards, staff without cards now have cards. 2.) Education provided regarding importance of food handlers cards and will be needed upon hire. 3.) Weekly, Monthly 4.) Executive Chef, Assistant Executive Director/BOM, Executive Director

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 240 and C 370.

Refer to tags C240 and C370

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 240.

Refer to C240

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

Refer to  C240

The findings of the kitchen inspection, conducted 06/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities. 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.

The findings of the first revisit to the kitchen inspection of 06/04/24, conducted 09/10/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities. 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.

The findings of the second re-visit to the kitchen inspection 06/04/24, conducted 12/09/24 through 12/11/24, 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 and OARs 411 Division 57 for Memory Care Communities .

Based on observation, interview and record review, it was determined the facility failed to investigate incidents or injuries of unknown cause to rule-out abuse or neglect, document all required areas of an investigation, and/or report to the local SPD office if abuse or neglect could not be ruled out, for 5 of 5 sampled residents (#s 1, 2, 4, 6 and 7) reviewed for incidents or injuries of unknown cause. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2018 with diagnoses including dementia. During survey interviews with staff, review of the resident's 07/23/23 service plan, 07/18/23 through 10/16/23 temporary service plans and charting notes, physician communications, and incident investigations were reviewed, and the following was identified: * 07/25/23 bruise to top of right hand; and * 08/14/23 bruising to both wrists and the back of both hands. There was no documented evidence the investigations of the occurrences included all the required components, were reviewed by the Administrator, and did not identify how abuse or neglect was ruled out. The occurrences were not reported to the local SPD office if abuse and/or neglect could not be ruled out. At the request of the survey team, all incidents above were reported to SPD before the survey team exited the facility on 10/20/23. The need to ensure injuries of unknown cause were immediately investigated, contained all required areas of documentation including if abuse and neglect could be ruled out and if not, the injuries were reported to the local SPD office was discussed with Staff 1 (ED), Staff 5 (RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings. 2. Resident 2 moved into the MCC in 10/2023 with diagnoses including dementia and history of falls. Resident 2 required a walker for mobility. Observations of the resident, interviews with staff, and review of the resident's temporary service plans, facility "charting notes", and incident investigations were completed. Observations of the resident from 10/17/23 to 10/19/23 revealed the resident required cueing assistance with transfers and step by step direction for bathroom use. Clinical records reviewed from 10/11/23 to 10/16/23 noted the following: * On 10/16/23 staff documented on facility "charting notes" that the resident had skin injuries and suspected fall. It was further noted that the resident had an abrasion to forehead, bruise and abrasion to bridge of nose, and skin tear on left arm that was approximately 3.0 x 5.0 x 4.5 cm. Staff documented on a 10/16/23 incident report that the resident did not remember what happened when staff found the injuries. Staff further documented "NA" to all questions in the investigation. There was no documented evidence the facility conducted an immediate investigation to reasonably conclude the skin injuries or suspected fall was not the result of abuse, and the facility lacked documentation of required investigative components including individuals present, a description of the event, follow-up action and Administrator's review. The need to investigate unknown injuries or an incident 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 2 (RCC), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/18/23 and 10/19/23. They acknowledged the findings. The surveyor requested Staff 5, Staff 6 and Staff 7 to report the incident to the local SPD office. Confirmation that the incident was reported to the local SPD was received prior to the survey team exiting from facility. 3. Resident 7 moved into the MCC in 10/2022 with diagnoses including Wernicke's dementia. Resident 7 required a wheelchair for mobility. Observations of the resident, interviews with staff, and review of the resident's 07/25/23 service plan, temporary service plans, facility "charting notes", and incident investigations were completed. a. Clinical records reviewed from 07/20/23 to 10/18/23 noted the following: On 07/22/23 staff documented on a facility charting notes that "the aggressive resident entered this residents [resident's] room and began hitting [him/her] ...[his/her] left shoulder hurts."; and * Staff documented on a 07/22/23 incident report that staff heard Resident 7 screaming for help. Staff ran into the resident's room and observed another resident "attacking" the resident. The document showed staff left blanks to all questions in the investigation. There was no documented evidence the incident had been thoroughly investigated to rule out the possibility of abuse and there was no documented evidence the incident was reported to the local SPD. On 10/19/23, the surveyor requested Staff 2 (RCC), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) report the incident to SPD. Confirmation that the incident was reported to local SPD was received prior to the survey team exiting from facility. The need to investigate incidents of suspected abuse and neglect, and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 5, Staff 6 and Staff 7 on 10/19/23 and 10/20/23. They acknowledged the findings. b. During the acuity interview on 10/16/23 the resident was identified as a smoker and required staff supervision during smoking. Clinical records reviewed from 07/20/23 to 10/18/23 noted the following: * On 07/22/23 staff documented on a facility "charting notes" that the resident had an open area on left foot. The resident went out to smoke and "cigarette dropped on my slipper and I didn't notice it until my slipper was smoking." * The resident's 07/25/23 service plan showed the resident smoked cigarettes and staff were responsible for the task; and * Staff documented on the 07/22/23 incident report "Resident notified CG [caregiving staff] ...another resident accidentally burned [his/her] foot while smoking." There was no documented evidence the incident had been thoroughly investigated to rule out the possibility of neglect due to the lack of supervision while Resident 7 was smoking and there was no documented evidence the incident was reported to the local SPD. On 10/19/23, the surveyor requested Staff 2 (RCC), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) to report the incident to SPD. Confirmation that the incident was reported to the local SPD was received prior to the survey team exiting from facility. The need to investigate incidents of suspected neglect and to report the incidents when the facility's investigation was unable to rule out neglect was discussed with Staff 5, Staff 6 and Staff 7 on 10/19/23 and 10/20/23. They acknowledged the findings. 4. Resident 6 was admitted to the MCC in 04/2022 with diagnoses including occipital lobe dementia and congestive heart failure. Observations of the resident, interviews with staff, and the resident's current service plan dated 09/10/23, interim service plans, charting notes, and incident reports were reviewed and identified the following: * 07/07/23 - unwitnessed fall with injury; * 07/28/23 - unwitnessed fall without injury; * 08/10/23 - unwitnessed fall with injury; * 08/17/23 - unwitnessed fall without injury; * 08/25/23 - unwitnessed fall without injury; and * 10/15/23 - bruise on top of the resident's left arm. There was no documented evidence the facility promptly investigated the incidents to rule out abuse and/or neglect, or reported incidents to the local SPD office if abuse and/or neglect could not be ruled out, and that the Administrator had reviewed the incidents. The facility was asked to self-report the incidents to the local SPD office and confirmation was provided on 10/19/23. The need to promptly investigate all incidents to rule out abuse and/or neglect was discussed with Staff 1 (ED), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings. 5. Resident 4 moved to the facility in 10/2022 with diagnoses including Wernicke's dementia and acute encephalopathy. Observations of the resident, interviews with staff, and review of the resident's 07/25/23 service plan, temporary service plans, facility charting notes, and incident investigations were completed. a. An incident report dated 08/14/23 revealed Resident 4 had been involved in a resident to resident altercation. The incident report stated Resident 4 was rocking back and forth in a chair in the dining room. A resident sitting across from Resident 4 requested s/he stop rocking. Resident 4 stated s/he "didn't have to". The other resident grabbed his/her cup and threw it across the table at Resident 4's face. There was no documented evidence the facility promptly investigated the incident to rule out abuse and/or neglect, or reported incident to the local SPD office if abuse and/or neglect could not be ruled out, and that the Administrator had reviewed the incident. During an interview on 10/17/23 with Staff 2 (RCC) it was confirmed the incident had not been reported to the local SPD office. This surveyor requested Staff 2 report the incident to the local SPD office. Documentation was provided to the survey team to confirm it had been reported to the local SPD office on 10/17/23 at 4:30 pm. The need to ensure resident incidents were reported to the local SPD office was discussed with Staff 5 (Health Services Director, RN) and Staff 6 (Regional RN) on 10/20/23. They acknowledged the findings. b. Staff noted the following incident in a facility charting note dated 09/21/23: Resident 4 was sitting next to another resident on the couch and s/he was rubbing Resident 4's hand and talking with him/her when the other resident bent forward and kissed Resident 4 on the lips. Resident 4 "did not seem bothered by it" and closed his/her eyes and went to sleep. The other resident was told s/he cannot kiss others and stated "no problem" in response. There was no documented evidence the facility promptly investigated the incident to rule out abuse and/or neglect, or reported incident to the local SPD office if abuse and/or neglect could not be ruled out and that the Administrator had reviewed the incident. An interview with Staff 2 on 10/17/23 at 12:40 pm revealed there was no documented evidence the incident had been investigated to rule out whether or not abuse and neglect had occurred and confirmed the incident had not been reported to the local SPD office. The surveyor requested Staff 2 report the incident to the local SPD office. Documentation was provided to the survey team to confirm it had been reported to the local SPD office on 10/17/23 at 4:30 pm. The need to ensure resident incidents were promptly investigated and reported to the local SPD office when the facility failed to protect residents from harm was discussed with Staff 5 (Health Services Director, RN) and Staff 6 (Regional RN) on 10/20/23. They acknowledged the findings.

1. All identified incidents for resident 1, 2, 4, 6, 7 during the state survey were faxed to APS prior to the survey team leaving. 2. All incident reports are to be reviewed by the administrator. The consultant team is reviewing incident reports and providing feedback. Staff will be trained on how to identify incidents, how to document incident observations and how to communicate incidents to RCC/Nurse/Administrator. All care staff to take the online OCP course Elder Abuse Prevention, Investigation, and Reporting by Nov 30. The clinical team will review incident reports and investigations during daily clinical meeting and report to APS as appropriate. 3. Daily, weekly, monthly. 4. RCC, nurse, administrator.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-to-resident altercations and elopement incidents were immediately reported to the local SPD or AAA office as suspected abuse and promptly investigated; and the facility failed to ensure injuries of unknown cause were immediately reported to the local SPD or AAA office as suspected abuse unless an immediate investigation reasonably concluded and documented the physical injury was not the result of abuse for 2 of 3 sampled residents (#s 8 and 10) whose incidents were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the memory care community in 10/2021 with diagnoses including dementia. The resident's service plan, dated 04/19/24, incident investigation reports, progress notes from 02/18/24 through 06/05/24, observations of the resident, and interviews with care staff during the survey indicated the resident was dependent on staff for ADL care and required staff assistance of toileting care. The resident's clinical record revealed the following: * 04/27/24 - "found small quarter sized bruise on [his/her] right bicep, color was purple." On 06/12/24 at 12:43 pm, Staff 2 (RCC) confirmed the physical injury had not been investigated nor reported to the local unit. The surveyor requested Staff 1 report the incident to the local SPD office. In a 06/12/24 interview with Staff 5 (Health Services Director/RN) and Staff 25 (Acting ED), they reported when staff identified skin issues, the skin issues would be reported to the facility nurse who would follow up on the skin injuries. They confirmed there was no incident report or other document confirming the facility conducted an immediate investigation into the injury to conclude the injury was not the result of abuse or neglect to Resident 8. On 06/12/24 at 2:41 pm, confirmation that the report had been sent to the local APD office was provided prior to survey exit. The need to ensure investigations into physical injuries of unknown cause were documented, to include the injuries were not the result of abuse or neglect, was discussed with Staff 2, Staff 5, and Staff 25 on 06/12/24. They acknowledged the findings. 2. Resident 10 was admitted to the facility in 05/2024 with diagnoses including Alzheimer's disease. A review of the resident's 05/01/24 initial service plan, progress notes dated 05/01/24 through 06/10/24, incident reports, and interim service plans (ISPs) were completed, and interviews were conducted. The following was identified: * 06/02/24 - Resident displayed "behaviors and agitation" after seeing two other residents sitting together watching TV: s/he was ". . . loudly yelling at care staff and slamming cupboard doors." * 06/03/24 - The resident had a verbal altercation with another resident which involved yelling, name-calling, and clenched fists, with no physical contact. * 06/06/24 - The resident was actively exit-seeking and ". . . attempting to push through staff when they come [sic] through the door . . ." Staff noted s/he also tried ". . . to figure out how [staff member] get [sic] out through the back and standing back by that door . . ." * 06/07/24 - The resident got through the doors of the locked unit and was in the front lobby on two occasions. * 06/08/24 - The resident followed a visitor out the door, ". . . pushed activitys [sic] directors [sic] face and pushed her out of the way . . .," and ". . . made it to the front lobby." S/he then went out of the building. Staff documented a MT was outside watching the resident, and the manager called 911. The resident was eventually calmed down by staff and returned to the unit. There was no documented evidence these incidents were immediately reported to the local SPD as suspected abuse or promptly investigated. In an interview on 06/11/24, Staff 2 (RCC) stated that on 06/03/24, when Resident 10 and another resident were yelling at each other, she separated the two and nothing further happened. She reported she did not think of the incident as a resident-to-resident altercation because there was no additional interaction between the two residents. On 06/12/24, the facility was asked to report the resident-to-resident altercation to the local SPD office because they failed to rule out abuse at the time of the incident. Confirmation of the report was received prior to survey exit. The need to immediately report all suspected abuse to the local SPD office and to promptly investigate all resident incidents was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 2 (Consultant RN) on 06/12/24. They acknowledged the findings.

1.) All identified incidents for resident 8 and 10 during state survey were faxed to APS prior to the survey team leaving and confirmed by survey team. 2.)  All incident reports are to be reviewed by the administrator.  The consultant team is reviewing incident reports and providing feedback.  Continued staff education on how to identify incidents, how to document incident observations and how/who to communicate incidents to RCC/Nurse/Adminstrator.  All care staff have taken the online OCP course Elder Abuse Prevention on November 30th,2023. Educate staff on Northstar Abuse Reporting and Incident Reporting policy and procedures\.  The clinical team will review incident reports and investigations during daily clinical meeting and report to APS as needed. 3.)  Daily, weekly, monthly 4.) RCC, LPN, RN, Executive Director, Assistant Executive Director

Based on observation, interview, and record review, it was determined the facility failed to immediately investigate an un-witnessed fall and an injury of unknown cause to reasonably conclude and document the incidents were not the result of neglect or abuse, and failed to report the incidents to the local SPD or AAA for 2 of 2 sampled residents (#s 12 and 13) whose incidents were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 12 moved into the memory care community in 03/2021 with diagnoses including dementia. The resident's service plan, dated 08/20/24, incident investigation reports, progress notes from 08/13/24 through 09/09/24, observations of the resident, and interviews with care staff during the survey indicated the resident required assistance from staff for ADL care. On 08/31/24 Resident 12 was noted to have a ..."skin tear (1.5 cm) from unknown origin on (R) ring finger...Res[ident] states that [s/he] does not know how the change to skin happened..." There was no documented evidence this injury was immediately reported to the local SPD as suspected abuse or promptly investigated. On 09/10/24 at 3:45 pm, Staff 35 (RN Health Services Director) confirmed the physical injury had not been investigated nor reported to the local unit. The surveyor requested Staff 35 report the incident to the local SPD office. Confirmation that the report had been sent to the local APD office was provided prior to survey exit. The need to ensure investigations of physical injuries of unknown cause were documented, to include the injuries were not the result of abuse or neglect, was discussed with Staff 26 (Executive Director), Staff 35 (RN Health Services Director), and Staff 36 (LPN Assistant Health Services Director) on 09/10/24 and 09/11/24. They acknowledged the findings. 2. Resident 13 was admitted to the facility in 06/2024 with diagnoses including Alzheimer's disease. The resident's service plan, dated 08/06/24, incident investigation reports, progress notes from 09/03/24 through 09/10/24, observations of the resident, and interviews with care staff during the survey indicated the resident required assistance from staff for ADL care. On 09/03/24 Resident 13 was noted to be found on the floor after care staff "...heard a thud..." There was no documented evidence this incident was immediately reported to the local SPD as suspected abuse or promptly investigated. On 09/10/24 at 3:45 pm, Staff 35 (RN Health Services Director) confirmed the un-witnessed fall had not been investigated nor reported to the local unit. The surveyor requested Staff 35 report the incident to the local SPD office. Confirmation that the report had been sent to the local SPD office was provided prior to survey exit. The need to ensure investigations of unwitnessed falls were documented, to include the falls were not the result of abuse or neglect, was discussed with Staff 26 (Executive Director), Staff 35 (RN Health Services Director), and Staff 36 (LPN Assistant Health Services Director) on 09/10/24 and 09/11/24. They acknowledged the findings.

1.) All indentified incidients for resident 12 and resident 13 found during state survey were faxed to APS prior to the survey team leaving and confirmed by the survey team. 2.) All incident reports are to be reviewed by the administrator.  The consultant team is reviewing incident reports and providing feedback.  Continued staff education on how to identify incidents, how to document incident observations and how/who to communicate incidents to RCC/Nurse team/ Executive Director. Incident report with additional information introduced to staff and community for use. All Staff have taken the online OCP course Elder Abuse Reporting upon hire or previously.  Staff educated on Northstar Abuse Reporting and Incident Reporting policy and procedures.  The clinical team will review incident reports and investigations during daily clinical meeting and report to APS as needed. 3.) Daily, Weekly, Monthly 4.) RCC, LPN, RN, Executive Director

Based on interview and record review, it was determined the facility failed to investigate an injury of unknown cause to rule out possible abuse or report to the local SPD office if abuse could not be ruled out for 1 of 1 sampled resident (#15) and to document all required areas of an investigation including administrator review for 1 of 2 sampled residents (#17) whose incidents were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. During the survey, Resident 18 was residing in the memory care community and had a diagnosis of dementia. During the acuity interview on 12/09/24, the resident was identified as having bruises on the abdominal area. An 11/15/24 charting note showed the resident had bruising on the lower right side of the abdomen, measuring 12 x 8 cm, dark in color with some green discoloration. Additionally, the lower left abdominal area had an 8 x 6 cm dark bruise. There was no documented evidence that the facility conducted an investigation to determine the cause of the skin injury. The incident was not reported to the local SPD office. The surveyor requested Staff 26 (ED) and Witness 1 (Consultant RN) report the incident to the local SPD office. A copy of confirmation that the report was sent to the SPD office was provided prior to exit. The need to ensure injuries of unknown cause were immediately investigated by the facility, and if abuse was not able to be reasonably ruled out, the injury was reported to the local SPD office, was discussed with Staff 26 and Witness 1 on 12/11/24 at 9:09 am. They acknowledged the findings. 2. Resident 17 was admitted to the facility in 04/2024 with diagnoses including dementia. During the acuity interview on 12/09/24, the resident was identified as having unwitnessed falls and resident-to-resident altercations. Resident 17's medical records and facility investigations were reviewed. The resident's service planned interventions for aggression was a scheduled and PRN behavior medication and for staff to use "warmth, bathing, or a meal/snack." Resident 17's service plan identified him/her as being a high fall risk and having a "recent fall." The fall interventions were for the resident to use "proper footwear" and ensure a "well lit and clutter free area to ambulate." The following investigations were reviewed: * 11/24/24: Resident-to-resident altercation; * 11/29/24: Resident-to-resident altercation; * 12/02/24: Unwitnessed fall at 9:30 am resulting in head and spine pain; * 12/02/24: Unwitnessed fall at 9:10 pm, after which Resident 17 reported pain; and * 12/07/24: Unwitnessed fall resulting in the resident hitting his/her head. There was no documented evidence the investigations had been reviewed by the Administrator. The need to ensure all investigations of suspected abuse had documented evidence of the Administrator's review was discussed with Staff 26 (ED), Staff 36 (LPN Assistant Health Services Director), Staff 37 (RN Health Services Director), and Witness 1 (Consultant RN) on 12/11/24 at 9:39 am. They acknowledged the findings.

1. Resident 15 report was sent to APS prior to survey leaving to community.  Administrator has reviewed and signed all investigations. 2. The Administrator will review, discuss, and sign incident reports during clinical meetings. The Administrator and nurses will review any new progress notes and other documentation daily during clinical meetings to ensure any potential incidents have been identified, investigated, and reported.  The Administrator, nurses, and resident care coordinator will complete daily walking rounds through all four resident cottages to observe resident care, talk with care staff, and inquire about any care concerns or observations including potential incidents. This communicates to all care staff, the leadership team's engagement and gives the staff an opportunity to approach with any questions or concerns if they are not sure about a situation. The leadership team will also be able to proactively observe staff-resident interactions. The consultant will review root cause analysis with the administrator, nurses, and resident care coordinator including education on five whys. 3. Daily, Weekly, Monthly, 4. Resident Care Coordinator, Nurses, Administrator

Based on interview and record review, it was determined the facility failed to immediately investigate incidents of abuse or suspected abuse relating injuries of unknown cause to rule out abuse or suspected abuse and report to the local SPD office if abuse could not be ruled out and report resident to resident altercations to the local office for 1 of 1 sampled resident (# 9). This is a repeat citation. Findings include, but are not limited to: Resident 9 moved into the memory care community in 05/2022 with diagnoses including Lewy Body dementia and Alzheimer's disease. The resident's facility records including progress notes, dated from 01/22/25 through 04/21/25, the 01/22/25 service plan, and Interim Service Plans, dated from 01/29/25 through 04/20/25, were reviewed. There was no documented evidence the following incidents were reported to the local SPD office or that the facility had immediately investigated the issue in order to rule out abuse or possible abuse: * 04/17/25: Resident to resident altercation; and * 04/20/25: Skin tear on left elbow. A copy of the confirmations that the facility reported the above incidents to the local SPD office was provided on 04/22/25. The need to ensure the facility immediately investigated incidents of abuse, suspected abuse, or an injury of unknown cause to rule out possible abuse or report to the local SPD office if abuse could not be ruled out was reviewed with Staff 43 (ED), Staff 44 (Consultant), Staff 45 (RN), Witness 1 (RN Consultant), and Witness 2 (RN Consultant) on 04/22/25 at 4:36 pm.

1. Resident #9 no longer resides in the community. The events listed in the survey have been reported as required, documentation of the reports was provided on 4/22/25. 2.Community employees have completed the Oregon Care Partners training titled "Elder Abuse Prevention and Investigation." The direct, call reporting line has been posted in each medication room for ease of use by staff when management is not in the building, to ensure timely reporting. All incidents are reviewed during community stand-up and clinical meetings the following business day. All incident investigations are completed by the community administrator with support from the IDT to ensure proper interventions, investigations, and reporting per the rule. 3.Monitoring will be completed using the Electronic Health Record system. The system logs and tracks each event and aids in appropriate and timely documentation. The community Administrator will review and monitor each report for proper investigation and reporting (if needed) prior to completion. 4.The Administrator will be responsible for assuring that Incident reports are monitored, investigated and reported to meet the regulation.

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests. Findings include, but are not limited to: At the time of the survey, the facility was home to 62 residents, consisted of four cottages (A, B, C and D), who resided in the Memory Care Community. During the survey, 10/16/23 through 10/20/23, there was a lack of scheduled activities that occurred in the facility. An activity calendar for the facility was requested on 10/16/23 during the entrance conference and Staff 2 (RCC) provided the activity calendar during the survey. Review of the monthly activity calendar for October 2023 showed the following: * 10:00 am - Morning meeting; and * 3:00 pm - Group activity. There were only two activities scheduled daily. Throughout the survey from 10/17/23 to 10/20/23, the two scheduled activities were not observed to take place during the survey. Residents were observed sitting in common areas for long periods of time, sleeping, while a television played continuously, walked the halls, or remained in their rooms unengaged in individual and/or group activities. On 10/19/23 and 10/20/23, failure to provide an activity program based on individual needs and group interests was reviewed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations). They acknowledged the findings.

1. The community is actively recruiting for an activities director. The marketing director is currently acting as the activity director designee and is creating the monthly calendar. A designated caregiver is ensuring activities are being done per the calendar and ensuring 1:1 activities are happening. 2. The activity calendar is being developed to have scheduled activities through the day and swing shift. Caregivers are being trained on how to perform both scheduled and spontanous actvites and are responsible for at least 50% of the individualized activities. 3. Daily, Monthly, Quarterly. 4. Marketing Director, Designated Caregiver, Administrator.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 2) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 2 moved into the memory care facility in 10/2023 with diagnoses including Alzheimer's disease. The resident's new move-in evaluation was reviewed and the following elements were not addressed: * Physical health status including visits to health practitioner(s) ER, hospital or NF in the past year; * Mental health issues including history of treatment and effective non-drug interventions; * Cognition, including decision making ability; * Personality including how the person copes with change or challenging situations; * Communication and sensory including ability to understand and be understood; * Independent activity of daily living including housework and laundry and transportation; * Pain including non-pharmaceutical interventions and how a person expressed pain or discomfort; * List of treatments including type, frequency and level of assistance needed; * Indicators of nursing needs including potential for delegated nursing tasks; * Emergency evacuation ability; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful prior to placements; and * Environmental factors that impact the resident's behavior including noise, lighting, room temperature. The need to ensure the move-in evaluation included all required elements was discussed with Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/18/23 at 11:00 am. They acknowledged the findings.

1. An up-to-date evaluation will be completed on Resident 2. All evaluations are being reviewed and an evaluation checklist is being provided by the consultant. 2. Education will be provided by the RN consultant to the health services team on how to conduct and document an evaluation to ensure all required evaluation items are included. The RCC is taking the OHCA course Role of the RCC. All evaluations will be reviewed for completeness. 3. Prior to move-in, 30-days and quarterly. 4. RCC, Nurse, Administrator

3. Resident 2 moved into the memory care facility in 10/2023 with diagnoses including Alzheimer's disease. There was no service plan for the resident. During an interview on 10/17/23 at 1:18 pm, Staff 20 (CG) confirmed there was no service plan for the resident. The need to ensure service plans were available to staff to follow was discussed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on  10/18/23 and 10/20/23. They acknowledged the findings. 4. Resident 3 moved into the memory care facility in 08/2020 with diagnoses including dementia. a. Resident 3's service plan, updated 11/03/22, temporary service plans and facility charting notes dated 07/19/23 through 10/13/23 were reviewed. Interviews with care staff were conducted and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas: * Dressing assistance; * Grooming assistance; * Shaving including frequency of services; * Oral care assistance; * Bathing; * Ambulation including the use of wheelchair versus walker; * Transfer assistance; * Toileting assistance; * Hospice service including when to contact and who to contact; and * Radio on all times. b. The most recent service plan, dated 11/03/22, was accessible to staff. There was no documented evidence the facility completed quarterly service plans for Resident 3. The need to ensure service plans were reflective of the resident's care needs, provided clear caregiving instructions, and were updated quarterly as required was discussed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/18/23 and 10/20/23. They acknowledged the findings. 5. Resident 6 was admitted to the MCC in 04/2022 with diagnoses including occipital lobe dementia and congestive heart failure. Observations of the resident, interviews with staff, and a review of the resident's current service plan dated 09/10/23, interim service plans, and charting notes dated 07/21/23 to 10/15/23 showed the service plan was not reflective of the resident's status and did not provide clear direction to staff in the following areas: * Two-person assistance and gait belt use with toileting, incontinence care, and transfers; * One-to-one meal assistance; * Significant weight loss; * Use of a wheelchair and assistance needed; and * Interventions to minimize falls. The need to ensure service plans were reflective of residents' status and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (ED), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs, were available to staff, were reviewed quarterly as required, and provided clear instruction to staff for 5 of 6 sampled residents (#s 2, 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 10/2022 with diagnoses including Wernicke's dementia, UTI (resolved), acute kidney injury (resolved) and acute encephalopathy. Interviews with care staff and observations of Resident 4 during the survey revealed s/he was dependent on staff for cueing for all ADL's and had a history of falls. Resident 4's current service plan, dated 07/25/23, failed to reflect the resident's care needs and lacked specific instruction to staff in the following areas: * Activities; * Fall interventions; and * Pain management and how pain was exhibited. The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 5 (Health Services Director, RN) and Staff 6 (Regional RN) on 10/20/23. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 03/2022 with diagnoses including Parkinson's disease and dementia without behavioral disturbance. Interviews with care staff and observations of Resident 5 during the survey revealed s/he received a mechanical soft diet and thickened liquids. Resident 5's current service plan dated, 10/02/23, failed to reflect the resident's care needs and lacked specific instruction to staff in the following areas: *Activities; and *Thickened liquids. The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 5 (Health Services Director, RN) and Staff 6 (Regional RN) on 10/20/23. They acknowledged the findings.

1. Service plans for resident 2, 3, 4, 5, & 6 will be updated to include all missing elements identified during survey. Consultant is providing instruction on service plan development with the team. A checklist is being provided by the consultant with all the required service planning elements. 2. Education will be provided by RN consultant to those responsible for completing the service plan. RCC taking the OHCA course Role of the RCC. A review of upcoming service plans will be done weekly during a clinical meeting. 3. Weekly, Monthly, Quarterly. 4. RCC, Nurse, Administrator.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs; included a written description of who should provide the services and what, when, how, and how often the services should be provided; and/or were implemented for 3 of 4 sampled residents (#s 8, 9, and 11) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the memory care community in 10/2021 with diagnoses including dementia. The resident's 04/19/24 service plan, and 02/05/24 through 05/10/24 temporary service plans were reviewed, observations were made, and interviews with caregivers were conducted on 06/10/24 and 06/11/24. Resident 8's service plan was not reflective, did not provide clear direction to staff, including what, when, how, and how often services should be provided, and was not implemented in the following areas: * Fall interventions; * Use of a wheelchair; * Daily routine; * Oral health care including use of denture; * Use of a gait belt with transfer; * As needed health shakes; * Daily walking exercise; and * Scheduled toileting. The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff, including what, when, how, and how often services should be provided, was discussed with Staff 2 (RCC) and Staff 25 (Acting ED) on 06/12/24. The findings were acknowledged. 2. Resident 9 moved into the memory care community in 05/2022 with diagnoses including Lewy Body dementia. The resident's 04/17/24 service plan and 03/20/24 through 05/23/24 temporary service plans were reviewed, observations were made, and interviews with caregivers were conducted on 06/10/24 and 06/11/24. Resident 9's service plan was not reflective and did not provide clear direction to staff, including what, when, how, and how often services should be provided, in the following areas: * Daily routine including shower time preferences; and * High protein snacks. The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff, including what, when, how, and how often services should be provided was discussed with Staff 2 (RCC) and Staff 25 (Acting ED) on 06/12/24. The findings were acknowledged. 3. Resident 11 was admitted to the facility in 03/2022 with diagnoses including Alzheimer's disease with behavioral disturbance. Review of the resident's 05/01/24 service plan revealed it was not reflective of the resident's current status and needs and/or did not provide clear direction regarding the delivery of services in the following areas: * Dressing preferences; * Visual and auditory hallucinations; * Food preferences; * Meal assistance needed; * Behaviors; * One-on-one activities for staff to attempt; * Fall interventions; and * Level of assistance needed with ADLs. The need for service plans to accurately reflect residents' current needs and provide clear direction to staff was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 2 (Consultant RN) on 06/12/24. They acknowledged the findings.

1.)  Service plans for resident 8, 9, and 11 will be updated to include missing elements identified during survey.  Consultant is continuing to provide instruction on service plan development with the team.  A checklist has been provided by the consultant with all the required service planning elements. 2.)  Education will continue to be provided by RN consultant to team members responisble for completing the service plan.  A review of upcoming service plans will be done weekly during a daily clinical meeting. 3.)  Weekly, Monthly, Quarterly 4.)  RCC, LPN, RN, Executive Director, Assistant Executive Director

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs, included a written description of how often the services should be provided, and were readily available to staff and provided clear direction regarding the delivery of services for 3 of 3 sampled residents (#s 12, 13, and 14) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 12 moved into the memory care community in 03/2021 with diagnoses including dementia. The resident's 08/20/24 service plan, and 08/28/24 through 09/03/24 temporary service plans were reviewed, observations were made, and interviews with caregivers were conducted on 09/10/24 and 09/11/24. The current service plan, dated 08/20/24, was not available to staff. Resident 12's service plan was not reflective, did not provide clear direction to staff, including what, when, how, and how often services should be provided, in the following areas: * Fall interventions; * Hospice services; * Bathing or showering frequency; * Health shakes; and * Weight loss. The need to ensure staff had access to service plans and service plans were reflective of the identified needs of the resident and provided clear direction including what, when, how, and how often services should be provided, was discussed with Staff 26 (ED), Staff 35 (RN Health Services Director), Staff 36 (LPN Assistant Health Services Director), and Witness 2 (Consultant RN) on 09/10/24 and 09/11/24. The findings were acknowledged. 2. Resident 13 moved into the memory care community in 06/2024 with diagnoses including Alzheimer's dementia. The resident's 08/06/24 service plan and 09/03/24 through 09/10/24 temporary service plans were reviewed, observations were made, and interviews with caregivers were conducted on 09/10/24 and 09/11/24. The current service plan, dated 08/20/24, was not available to staff. Resident 13's service plan was not reflective and did not provide clear direction to staff, including what, when, how, and how often services should be provided, in the following areas: * Anxiety; * Walking to exhaustion; * Bathing or showering frequency; and * Chronic back pain. The need to ensure staff had access to service plans and service plans were reflective of the identified needs of the resident and provided clear direction to staff, including what, when, how, and how often services should be provided was discussed with Staff 26 (ED), Staff 35 (RN Health Services Director), Staff 36 (LPN Assistant Health Services Director), and Witness 2 (Consultant RN)on 09/10/24 and 09/11/24. The findings were acknowledged. 3. Resident 14 was admitted to the facility in 04/2023 with diagnoses including dementia. The resident's 08/08/24 service plan and 08/02/24 through 08/28/24 temporary service plans were reviewed, observations were made, and interviews with caregivers were conducted on 09/10/24 and 09/11/24. The current service plan, dated 08/08/24, was not available to staff. Resident 14's service plan was not reflective and did not provide clear direction to staff, including what, when, how, and how often services should be provided, in the following areas: * Assistive devices; * Specific fluid restriction directions; and * Bathing or showering frequency. The need to ensure staff had access to service plans and service plans were reflective of the identified needs of the resident and provided clear direction to staff, including what, when, how, and how often services should be provided, was discussed with Staff 26 (ED), Staff 35 (RN Health Services Director), Staff 36 (LPN Assistant Health Services Director), and Witness 2 (Consultant RN) on 09/10/24 and 09/11/24. The findings were acknowledged.

1.) Service plans all printed and placed in appropriate binders in cottages prior to the survey team exiting community.  Service plan for resident 12, 13, 14 were updated to include missing elements identified during survey. All service plans have been updated with shower days. 2.) Education will be continued to be provided by RN consultant to team members responssible for completing the service plan. A schedule will be developed for quarterly review. All service plans will be updated prior to move-in, 30-days, quarterly, and with any significant change in condition. 3.) Weekly, Monthly, Quarterly 4.) Executive Director, LPN

2. Resident 15 was admitted to the facility in 05/2023 with diagnoses including schizophrenia and dementia. Observations were made of the resident's care on 12/09/24 through 12/10/24, interviews with the facility staff were conducted, and the current service plan, dated 08/19/24, was reviewed. a. Resident 15's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Hospice services; * Refusals of shower; * Refusals of mouth care and personal hygiene; * Unsteady gait; * Increased assistance in toileting use; and * Weight loss. b. The service plan had not been updated quarterly as required. The need to ensure the service plan was updated quarterly, reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 26 (ED) and Witness 1 (Consultant RN) on 12/11/24 at 9:09 am. 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 provided clear directions to staff regarding the delivery of services, changes and entries made to the service plan were dated and initialed, were implemented, and completed quarterly for 3 of 3 sampled residents (#s 15, 16, and 17) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 16 was admitted to the facility in 10/2024 with diagnoses including depression with psychotic features, generalized anxiety, left-side affected stroke, and vascular dementia. Observations were made of the resident's care on 12/10/24, interviews with the resident and facility staff were conducted, and the current service plan, dated 11/07/24, was reviewed. Resident 16's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * How a person expresses pain, anxiety or discomfort; * Personality, including how the person copes with change or challenging situations; * How a person expresses memory loss; * Instructions on signs and symptoms of complications to report while on anti-depressant and anti-anxiety therapies; * Instructions on fall prevention; * Skin integrity and instructions on to whom to report skin impairments; * Instructions for signs and symptoms of complications to report while monitoring surgical incisions; * Instructions to staff on providing care to the resident with left-sided weakness secondary to a history of stroke; * Incorrect reference to resident requiring wheelchair for assistance with mobility; * Recent losses; * Smoking; * Alcohol and drug use; * Instructions on signs and symptoms for potential allergic reaction to Bupropion; * Instructions on signs and symptoms of post-fall injury to report; and * Instructions on signs and symptoms of dehydration to report. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 26 (ED) and Witness 1 (Consultant RN) on 12/11/24. They acknowledged the findings. 3. Resident 17 was admitted to the facility in 04/2024 with diagnoses including dementia. The resident's service plan, dated 08/10/24, and Interim Service Plans were reviewed, staff were interviewed, and the resident was observed. The service plan did not provide clear direction to staff regarding the delivery of services, and/or was not implemented in the following areas: * Activities; * Presence of a roommate; * PRN medications for behaviors; * Behavior interventions including family contact information for staff to utilize; * Dressing; * Falls; * Bathing; * Toileting assistance needed including incontinent products used; * Escorts needed for appointments outside of the community; * Mobility device; * Key use; * Pain interventions; * The use of chocolate desserts to help redirect escalating behaviors towards other residents; * Preference to have sheets on his/her bed; and * Monthly weights. Additionally, the service plan had not been updated quarterly and updates were not dated or initialed. The need to ensure the resident's service plan was reflective of their current care needs and provided clear directions to staff regarding the delivery of services, changes and entries made to the service plan were dated and initialed, were implemented, and completed quarterly was discussed with Staff 26 (ED), Staff 36 (LPN Assistant Health Services Director), Staff 37 (RN Health Services Director), and Witness 1 (Consultant RN) on 12/11/24 at 9:39 am. They acknowledged the findings.

1. The service plans for residents 16, 15, 17 were updated to include missing elements identified during survey.  Services plan updates have been dated. 2. A service plan schedule has been implemented. All resident service plans will be reviewed and updated as needed. Consultant will review a select number of service plans for completeness and accuracy during scheduled visits. The Admnistrator and nurses will complete the NurseLearn course "Individualized Care/Service Plans." 3. Weekly, Quarterly 4. Administrator, Scheduler, LPN, RCC

2. Resident 20 moved into the memory care community in 09/2021 with diagnoses including Alzheimer's disease and hypertension. Observations of the resident, interviews with facility staff, and the 04/16/25 service plan and Interim Service Plans, from 01/24/25 through 04/13/25, reviewed during the survey, revealed Resident 20's service plan was not reflective of his/her status and did not provide clear direction regarding the delivery of services in the following areas: * Use of a floor mat while in bed; * Use of a soft brace to the arm while in bed; * Conflicted information related to shower status; * Activity status including preferences; * Hospice services status; * Repositioning every two hours; * Skin status on legs; * Use of a cushion while in wheelchair; and * Use of anti-depression medication. On 04/22/25 approximately at 2:10 pm, the need to ensure service plans were reflective of resident needs and preferences and provided clear direction to staff was discussed with Staff 43 (ED), Staff 44 (Consultant), Staff 45 (RN), Witness 1 (RN Consultant), and Witness 2 (RN Consultant). They acknowledged the findings. 3. Resident 4 moved into the memory care community in 10/2022 with diagnoses including Wernicke encephalopathy. Observations of the resident, interviews with facility staff, and the 02/06/25 service plan and Interim Service Plans, dated from 01/10/25 through 04/20/25, were reviewed during the survey and revealed Resident 4's service plan was not reflective of his/her status and did not provide clear direction regarding the delivery of services in the following areas: * Would put self in shower; * Attending Bible study in the facility every Sunday; * What genre of music the resident enjoys; * Fall interventions; * How the resident communicates unmet needs, including pain and need for connection; and * Resident 4's routine of being up and walking throughout the day and night and then mostly sleeping for the following 24 hours. The need to ensure service plans were reflective and provided resident specific instruction was discussed with Staff 43 (ED), Staff 44 (Consultant), Staff 45 (RN), Witness 1 (RN Consultant), and Witness 2 (RN Consultant) on 04/22/25 at 5:19 pm. They acknowledged the findings. 4. Resident 9 moved into the Memory Care Community in 05/2022 with diagnoses including Lewy Body dementia and Alzheimer's disease. Observations of the resident, interviews with facility staff, and the 01/22/25 service plan and Interim Service Plans, dated from 01/29/25 through 04/20/25, were reviewed during the survey and revealed Resident 9's service plan was not reflective of his/her current status, did not provide clear direction regarding the delivery of services, and/or was not implemented in the following areas: * How often the resident was assisted to the restroom; * Meal assistance including ability to feed self and the need for cueing/redirection; * Ability to communicate; * Interventions for re-directing behaviors; * ADLs including shaving and brushing his/her teeth; * Skin issues; and * The use of glasses. The need to ensure service plans were reflective and provided resident specific instruction was discussed with Staff 43, (ED), Staff 44 (Consultant), Staff 45 (RN), Witness 1 (RN Consultant), and Witness 2 (RN Consultant) on 04/22/25 at 5:19 pm. 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, provided clear direction regarding the delivery of services, and/or were implemented for 4 of 4 sampled residents (#s 4, 9, 19, and 20,) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 19 moved into the memory care community in 04/2023 with diagnosis including cognitive dysfunction, leukoencephalopathy  (a rare brain infection), and dysphasia. The current service plan dated 04/21/25 and Interim Service Plans were reviewed, observations were made, and interviews with facility staff were conducted. The following was identified:   The resident's service plan lacked resident specific instruction, was not reflective of the resident's current status, and/or was not implemented in the following areas: * Significance of the baby doll the resident had with him/her; * Frequency and time of safety checks; * Lack of footwear used and instruction relating to non-slip socks; * Current diet order; * Clear instruction to staff regarding nutrition and hydration; * Catheter care that included clear direction to staff; * Recent hospitalizations; * Recent falls and fall interventions; * Toileting assistance that included number of staff, frequency, and resident specific instruction; * Incontinent assistance and brief changes that included number of staff, frequency, and resident specific instruction; * Transfer status that included number of staff and instruction; * Pain interventions including use of ice pack for shoulder; * Change in ability to use his/her right arm after a fall; * Shower instruction that included number of staff and resident specific instruction; and * Diagnosis of leukoencephalopathy and how it impacted ADL care. The need to ensure service plans were reflective, provided resident specific instruction, and was implemented was reviewed with Staff 43 (ED), Staff 44 (Consultant), Staff 45 (RN), Witness 1 (RN Consultant), and Witness 2 (RN Consultant) on 04/22/25 at 2:24 pm. They acknowledged the findings.

1. Resident #9 no longer resides in the community. For residents 4, 19, and 20, the community has reviewed and updated the service plans to be sure that they are person-centered and meet the resident's needs in a way that supports dignity, privacy, choice, individuality and independence. 2. Each resident will have an evaluation completed with a person-centered service plan initiated upon move- in, and at least quarterly or with a significant change thereafter. Training has been provided to appropriate staff on how to complete the person- centered service plan to include personalization, resident choice/routine and staff direction on how to meet those needs. The service plans will be available in the Electronic Health Record (EHR) and on the floor in each community for staff access. 3. Random service plan audits will be conducted monthly for three months to assure they are person-centered, appropriate and reflect the resident's status and needs and will include staff direction to meet those needs. 4. The Administrator will be responsible for assuring that service plans are monitored on-going to meet the regulation.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had significant changes of condition were evaluated, referred to the facility RN and service plans updated, failed to monitor and document what actions or interventions were needed for short-term changes of condition, including resident-specific instructions communicated to staff on each shift and made part of the resident's record with weekly progress noted through resolution for 1 of 6 sampled residents (#6) who experienced severe weight loss, multiple falls with injuries and pain. Findings include, but are not limited to:   Resident 6 was admitted to the MCC in 04/2022 with diagnoses including occipital lobe dementia and congestive heart failure. Review of the resident's record, including weight records dated between 04/21/23 and 10/16/23, the most recent service plan and evaluation, interim service plans, 10/01/23 through 10/16/23 MAR, incident reports, and charting notes dated between 07/21/23 and 10/16/23, interviews and observations with staff and the resident were conducted between 10/17/23 and 10/20/23. a. Weight records from 04/2023 through 10/2023 indicated the resident weighed: * 04/21/23: 156.4 lbs.; * 08/03/23: 153 lbs.; * 09/03/23: 144.8 lbs.; and * 10/16/23: 134.2 lbs. The resident lost 8.2 lbs. between 08/03/23 and 09/03/23, which was a 5.3% loss of his/her total body weight. This represented a significant weight loss in 31 days and constituted a significant change of condition. The resident experienced a 22.2 lb. weight loss from 04/21/23 to 10/16/23 which was a 14.1% severe weight loss in six months and constituted a significant change of condition. There was no documented evidence the facility RN was notified of the resident's weight loss; actions or interventions were determined, communicated to staff on all shifts, and implemented; or interventions were monitored for effectiveness. On 10/18/23, the surveyor requested Resident 6's weight. Staff 16 (CG) reported the resident's weight was 137.2 lbs. Meal observations on 10/18/23 and 10/19/23 revealed Resident 6 was unable to feed  him/herself, required one to one meal assistance from staff, and ate approximately 25% of his/her meals. Multiple interviews with staff throughout the survey indicated the resident began to decline approximately "a couple of months ago" and required full assistance with meals. During an interview on 10/18/23 with Staff 5 (Health Services Director, RN) and Staff 6 (Regional RN) it was confirmed there was no documented evidence an RN had assessed the weight loss or decline in the resident's ability to feed him/herself. The facility failed to evaluate Resident 6's severe weight loss, determine what actions or interventions were needed, communicate the actions or interventions to staff, and refer the weight loss to the RN for further assessment. The resident continued to lose weight. b. Resident 6's current service plan dated 09/10/23 indicated the resident had a history of falls and had experienced multiple falls since the last evaluation. On 5/11/23 the resident sustained a fracture to his/her right foot from a fall. The service plan directed staff to ensure the resident wore nonskid socks. The service plan noted the resident had vision impairments, was mostly non-verbal, and required one staff partial assist with transfers with use of rollator walker. Observations of the resident from 10/17/23 to 10/19/23 noted the resident required two-person assistance with a gait belt for transfers, full assistance with meals, used a wheelchair with staff assistance, and was unable to ambulate. The resident's charting notes, and incident reports dated 07/07/23 through 08/04/23 identified the following: * 07/07/23 2:00 pm - Care Staff were in the med room and heard a "thud sound". The resident was found in the living room sitting on the floor. As care staff moved the resident to the couch the resident said, "stop I hurt." It was noted the resident randomly said, "I hurt" during the ten minutes of having his/her vitals taken." * 07/28/23 5:37 pm - Care staff found the resident sitting on floor in front of his/her wheelchair. * 08/01/23 1:32 pm - Care staff heard a "thud" the resident was found in the living room laying down on the floor. The resident would not allow care staff to touch him/her. The resident was sent to the emergency department. * On 08/04/23 an RN charting note documented the resident has had 14 falls since physical therapy was discontinued on 03/22/23. Thirteen falls were non-injury and one injury fall resulted in a fractured right foot on 05/11/23. There were no interventions or actions put in place to prevent further falls. The resident's charting notes, and incident reports dated 08/10/23 through 10/16/23 identified the following: * 08/10/23 1:30 pm - Care Staff heard a "thud" and the resident was found in the living room, laying on his/her back. Resident 6 was sent to the emergency department. * 08/13/23 5:38 am - Care Staff documented the resident had an assisted fall to the floor with injuries. Staff noted that during a transfer from the wheelchair to the toilet the resident's legs gave out and was assisted to the floor. The resident sustained an abrasion to the top left back area and had an open area to his/her elbow. * 08/17/23 7:28 pm - Care Staff documented a resident was heard yelling that Resident 6 had fallen and was on the floor. Care Staff observed Resident 6 on the floor, in a seated position. * 08/23/23 9:52 pm - Care Staff noted the resident was trying to sit back down in his/her wheelchair, and while staff was helping another resident, Resident 6 missed his/her wheelchair. The "resident had complained of pain in his/her bottom", "no signs or symptoms of bruising or redness." * 08/25/23 6:34 pm - Care staff found the resident sitting on floor against the couch. * 10/03/23 - Care Staff documented the resident was sent out to the hospital to be evaluated for a possible left ankle fracture. * 10/11/23 - Care Staff noted the resident was removed from alert for return from hospital. "Hospital said [s/he] was fine did not break or hurt anything." "[Resident 6's]  mobility is back at base line." The resident experienced an additional five falls between 08/10/23 through 10/16/23, had multiple emergency department visits due to the falls, physical injuries, and pain. The facility failed to thoroughly evaluate each fall to identify and document factors that might have contributed to the resident's falls. Although actions and interventions were noted in incident reports and progress notes, there was no documented evidence they were communicated to staff on all shifts and monitored for effectiveness. This placed Resident 6 at further risk of repeated falls and injuries. c. Resident 6's charting notes reviewed from 07/21/23 through 10/16/23 identified the following: * 07/21/23 - Care Staff documented when toileting the resident, a "mass like bump" was observed on the resident's "upper stomach." Staff noted, "[Resident 6] did show signs of pain when touching it. Staff notified the LPN, and she stated it was a bug bite. * 07/22/23 - The LN documented, "[Resident 6] has a history of having this type of lump appearing and resolving" and notified the PCP for further instructions. * 08/07/23 - Care Staff documented the PCP responded to the fax about [Resident 6] having a lump on abdominal area...Feels like a possible hernia but is not causing [him/her] any pain...Monitor for now." * 10/11/23 - Care Staff documented the "resident had very strong foul smell when [s/he] urinates. No complaints of pain or discomfort when [s/he] is toileting." During an interview on 10/19/23, Staff 16 reported the resident still had the mass on his/her stomach. A visible raised area was observed on the resident's abdomen and was noticeable below his/her clothing. On 10/19/23, the observation and documentation related to the resident's abdominal mass was discussed with Staff 5 and Staff 6. Staff 5 was unaware of the resident's condition. There was no documented evidence the facility identified resident specific interventions regarding the changes of condition, communicated the interventions to all staff, and monitored the resident according to his/her evaluated needs. The need to ensure changes of condition were identified, reported to the RN if determined to be a significant change of condition, interventions determined, documented, and communicated to staff with monitoring occurring per the resident's evaluated needs was discussed with Staff 1 (ED), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.

1. RN completed significant change of condition for resident 6. Clinical meetings are being scheduled as well as full documentation review to identify changes of condition.  A 24-hour book is being used with ISPs. Weekly weights will be reviewed by the RN and assessments completed weekly. RN to assess fall interventions and ADLs and implement ISPs and update service plan as appropriate. 2. Clinical meetings for review of change fo condition multiple times per week. ISPs and alert charting will be reviewed in the clinical meeting. Education will be provided to care staff about the difference between significant change and short-term change of condition and how to communicate to nursing. Training will be provided by the consultant to the nursing team on how to recognize, respond, monitor, and document changes in condition. A white board will be utilized to track  change of condition and will be updated daily and as needed. 3. Daily, Monthly, Quarterly. 4. RCC, Nurses, Administrator

Based on observation, interview, and record review, it was determined the facility failed to evaluate changes of condition; failed to determine and document what actions or interventions were needed for the resident; failed to communicate determined actions or interventions with staff on each shift; failed to ensure the actions or interventions were resident-specific and made part of the resident record; and/or failed to monitor the changes through resolution, with at least weekly documentation of progress, for 3 of 4 sampled residents (#s 8, 10, and 11) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:   1. Resident 8 was admitted to the MCC in 10/2021 with diagnoses including dementia. Review of the resident's record, including the most recent service plan, interim service plans, incident reports, and charting notes dated between 02/05/24 and 06/05/24, interviews with staff, and observations of the resident were conducted on 06/10/24 and 06/11/24. The following was revealed: There was no documented evidence resident-specific actions or interventions were determined for the following short-term changes of condition, that the determined actions or interventions were communicated to staff on all shifts, that the resident was monitored consistent with his/her evaluated needs and service plan, and/or that weekly progress was noted through resolution: * 04/27/24 - Bruise on the right upper arm; * 05/29/24 - Found on floor with "bruising and redness above left eyebrow and on left cheek."; and * 06/03/24 - Found on floor. The need to ensure resident-specific actions or interventions were determined and documented, communicated to staff on each shift, and the conditions were monitored consistent with the resident's evaluated needs, with progress noted at least weekly until resolved was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), and Staff 25 (Acting ED) on 06/12/24. They acknowledged the findings. 2. Resident 10 was admitted to the facility in 05/2024 with diagnoses including Alzheimer's disease. During the acuity interview on 06/10/24, Staff 2 (RCC), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 1 (Consultant RN) reported Resident 10 may become aggressive if s/he was approached for an interview and would notice if s/he were observed in an obvious manner. Based on this information, the resident was not interviewed during the survey. The resident's 05/01/24 initial service plan, progress notes dated 05/01/24 through 06/10/24, incident reports, and interim service plans (ISPs) were reviewed, and interviews were conducted. The resident experienced the following: * 05/14/24 - Exit-seeking behavior; * 06/03/24 - Resident-to-resident altercation; and * 06/06/24 - Exit-seeking behavior. The resident was put on alert charting for these short-term changes of condition. However, there was no documented evidence that the changes were evaluated; that resident-specific actions or interventions were determined, documented, communicated to staff on all shifts, and made part of the resident's record; or that the resident was monitored consistent with his/her evaluated needs and service plan. The need to evaluate changes of condition, determine and implement resident-specific interventions, and monitor the resident consistent with his/her evaluated needs and service plan was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 2 (Consulting RN) on 06/12/24. They acknowledged the findings. 3. Resident 11 was admitted to the facility in 03/2022 with diagnoses including Alzheimer's disease with behavioral disturbance. The resident's 05/01/24 service plan, progress notes dated 03/04/24 through 06/07/24, incident reports, and interim service plans (ISPs) were reviewed, and interviews were conducted. The resident experienced the following: * 05/25/24 - fall with arm pain; and * 05/31/24 - aggressive behavior toward staff. The resident was put on alert charting for these short-term changes of condition. However, there was no documented evidence the changes were evaluated; that resident-specific actions or interventions were determined, documented, communicated to staff on all shifts, and made part of the resident's record; or that the resident was monitored consistent with his/her evaluated needs and service plan. The need to evaluate changes of condition, determine and implement resident-specific interventions, and monitor the resident consistent with his/her evaluated needs and service plan was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 2 (Consulting RN) on 06/12/24. They acknowledged the findings.

1.)  Resident 8 service plan will contain resident specific actions and interventions, consistent with the residents need and progress noted at least weekly.  Resident 10 service plan evaluated for change of conditionand monitoring.  Resident 11 service plan evaluated for change of condition, evidence the changes were evaluated.   2.)  Daily clinical meetings for review of change of condition will occur.  ISPs and alert charting will be reviewed during the daily clinical meeting.  Eduation to care staff on short-term change of conditions and how to communicate to LPN and RN.  White board will be updated to keep track of change of condition and will be updated as needed. 3.)  Daily, Monthly, Quarterly 4.)  RCC, LPN, RN, Executive Director, Assistant Executive Director

Based on observation, interview, and record review, it was determined the facility failed to evaluate and monitor residents specific to evaluated needs and service planned interventions for 1 of 2 sampled residents (# 13) reviewed for falls. This is a repeat citation. Findings include, but are not limited to: Resident 13 was admitted to the facility in 06/2024 with diagnoses of dementia and was evaluated to be at risk for falls. Resident 13 was observed during the survey to ambulate with the use of a four-wheeled walker. Resident 13's current service plan indicated the resident was a fall risk and provided interventions to reduce falls. Resident 13's clinical record revealed the resident was found on the floor on 09/03/24. There was no documented evidence Resident 13's fall interventions were evaluated and monitored for effectiveness. The need to monitor interventions related to the falls experienced by Resident 13 was reviewed with Staff 26 (ED),  Staff 35 (RN Health Services Director) and Staff 36 on (LPN Assistant Health Services Director) on 09/10/24 and 09/11/24. They acknowledged the findings.

1.) Resident 13 intermittent service plan updated for FWW walker and fall risk and interventions to communicate resident changes to care staff. . 2.) Daily clinical meetings with clinical meeting process for review of change of condition.  ISPs and alert charting will be reviewed during the daily clinical meeting.  Education with staff regarding short-term change of conditions and how to communicate with nursing team. 3.) Daily, Monthly, Quarterly 4.) LPN, RN

2. Resident 15 was admitted to the facility in 05/2023 with diagnoses of dementia. During the acuity interview on 12/09/24, the resident was identified as having recent weight loss and as a result, the resident was enrolled in hospice services. Resident 15 was observed during the survey to walk and eat independently without any issues. The resident's service plan, dated 08/18/24, and a Temporary Service Plan, dated 11/21/24, did not indicate the resident's weight loss status. Resident 15's weight record was reviewed during the survey and revealed the following: * 08/07/24: 147.5 pounds: * 11/08/24: 143.5 pounds; and * 12/10/24: 141.0 pounds (during the survey). The weight records showed the resident lost 2.5 pounds, or 1.7 % of his/her body weight from 11/2024 to 12/2024 in a month. It was not a significant change of condition. There was no documented evidence the facility determine what resident-specific action or intervention was needed for the resident, communicated the determined action or interventions to staff and documented weekly progress note until the condition resolved. 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 26 (ED) and Witness 1 (Consultant RN) on 12/11/24 at 9:09 am. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document weekly progress until the condition resolved for 3 of 3 sampled residents (#s 15, 16 and 17) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 16 was admitted to the facility in 10/2024 with diagnoses including depression with psychotic features, generalized anxiety, left-side affected stroke, and vascular dementia. Clinical records, including the current service plan and progress notes, dated from 11/10/24 through 12/09/24, were reviewed, and interviews with facility staff and the resident were conducted. The following 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, and/or documented weekly progress until the condition resolved: 11/27/24: new orders for hydrocodone-acetaminophen 5-325 mg, oxycodone-acetaminophen 5-325 mg, and morphine ER 15 mg; 11/28/24: " ...continued to have edema" in the genital area; 11/28/24: "Pain was reported with movement due to surgical incisions."; 12/03/24: unwitnessed fall; 12/04/24: "Resident c/o [complained of] severe pain coming from hernia" in the genital area during primary care provider visit ...; and 12/04/24: returned from ER with a diagnosis of "swelling" in the right area of genital region . The need to ensure the facility evaluated the resident and 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 26 (ED) and Witness 1 (Consultant RN) on 12/11/24. They acknowledged the findings. 3. Resident 17 was admitted to the facility in 04/2024 with diagnoses including dementia. The resident's service plan, dated 08/10/24, Interim Service Plans, progress notes, dated 11/09/24 through 12/09/24, and 12/01/24 through 12/09/24 MAR were reviewed. Staff were interviewed and the resident was observed. The following changes of condition were identified: * 11/24/24: Resident to resident altercation; * 11/29/24: Resident to resident altercation; * 12/02/24: Unwitnessed fall at 9:30 am; * 12/02/24: Unwitnessed fall at 9:10 pm; and * 12/07/24: Unwitnessed fall. There was no documented evidence Resident 17's changes of condition had resident specific actions or interventions determined, the actions or interventions were communicated to staff on each shift, or progress was noted weekly through resolution. On 12/09/24 at approximately 5:00 pm, Staff 37 (RN Health Services Director) verified Resident 17 would cease behaviors towards other residents if offered "chocolate cake" or ice cream. He reported ice cream was available on the unit "at all times". When looking through the kitchenette on 12/09/24, Staff 37 verified the desserts were not available to staff at that time. The chocolate dessert intervention was not documented in the resident's record and had not been made available to staff. The need to ensure the facility determined what resident-specific actions or interventions were needed, the actions or interventions were communicated to staff on each shift, and progress was noted through resolution was discussed with Staff 26 (ED), Staff 36 (LPN Assistant Health Services Director), Staff 37 (RN Health Services Director), and Witness 1 (Consultant RN) on 12/11/24 at 9:39 am. They acknowledged the findings.

1. Resident 16's 90-day medication orders were sent to PCP for review and signature. ATSP is in place for pain and swelling of scrotum; TSP in place for fall intervention; resident added to weekly skin rounds for scrotal swelling. Resident 15 - the RN and LPN completed a root cause analysis on weight loss prior to hospice and interventions were implemented. Resident 17 - interventions for resident to resident concerns implemented and nursing assessment in place; TSP in place for chocolate dessert intervention.  Interventions for both falls to be communicated to staff via TSP based on root cause analysis. Weekly audit of progress notes and other documentation completed by consultant and administrator to review change of condition response. 2. Clinical meetings are scheduled Monday-Friday, and will include the Administrator, LPN, RN, and RCC/ staffing coordinator. The Administrator, RN, and LPN will complete the NurseLearn Module 1 by alleged date of compliance. Every other Wednesday beginning, at 6AM and 6 PM shift change, a staff meeting will be held with a standing agenda of abuse and neglect reporting, investigation, and documentation. The LPN will apply to and complete the NurseLearn Enhanced Program starting January 3, 2025 with the support from the Administrator to block time off each week for program requirements. 3. Daily, Weekly, Monthly 4. Administrator, Nurses, RCC, Staffing Coordinator

Based on observation, interview and record review, it was determined the facility failed to ensure the RN conducted an assessment when residents experienced a significant change of condition, failed to develop interventions based on the results of the assessment, and failed to update the service plan for 1 of 2 sampled residents (#6) who experienced significant changes of condition. Resident 6 experienced severe weight loss, multiple falls with injuries, and pain. Findings include, but are not limited to: Resident 6 was admitted to the MCC in 04/2022 with diagnoses including occipital lobe dementia and congestive heart failure. a. A review of Resident 6's weight records showed the resident had experienced a severe weight loss between 04/21/23 (156.4 lbs.) and 10/16/23 (134.2) of 22.2 pounds or 14.1% severe weight loss in six months and constituted a significant change of condition, and between 08/03/23 (153 lbs.) and 09/03/23 (144.8 lbs.) the resident lost 8.2 lbs which was a 5.3% loss of his/her body weight. This represented a significant weight loss in 31 days and constituted a significant change of condition. There was no documented evidence the facility RN had completed a significant change of condition assessment for the weight loss, which included documented findings, resident status interventions made as a result of an assessment or had updated the service plan as appropriate. The resident continued to lose weight. Refer to C 270, example a. b. A review of Resident 6's charting notes and incident reports dated 07/07/23 through 10/16/23 identified the resident experienced eight falls between 07/07/23 through 10/16/23, multiple emergency department visits due to the falls, physical injuries, and pain. Interviews with staff throughout the survey indicated the resident had a significant decline in transfers, mobility, toileting, and eating independently. Observations of the resident from 10/17/23 to 10/19/23 noted the resident required two-person assistance with a gait belt for transfers, full assistance with meals, used a wheelchair with staff assistance and was unable to ambulate. There was no documented evidence the facility RN had completed a significant change of condition assessment for the resident's overall functional decline, repeated falls with injuries, and pain which included documented findings, resident status, interventions made as a result of an assessment or had updated the service plan as appropriate. This placed Resident 6 at further risk of repeated falls and injuries. Refer to C 270, example b. On 10/20/23, the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 1 (ED), Staff 6 (Regional RN) and Staff 7 (VP of Operations). They acknowledged the findings.

1. RN completed significant change of condition for resident 6 and interventions put in place regarding significant weight change, falls, and decline in ADLs. Weekly and monthly weight monitoring is in place. The RN is documenting progress weekly and is evaluating the effectiveness of interventions implemented for significant change of condition. Care staff will be trained in notifying RN of significant change of condition. 2. Clinical meetings for review of change of condition. The consultant will provide training to the RN on how to recognize, respond, monitor and document significant change of condition. Weight monitoring and tracking will be done weekly/monthly and the white board will be updated during the clinical meeting. Education will be provided to care staff on the differences between a significant change and short-term change of condition and how to communicate this to the RN. 3. Daily, weekly. 4. RN, Administrator

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 2 of 2 sampled residents (#s 1 and 7) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task. 1. Resident 1 was admitted to the facility in 09/2018 with diagnoses including diabetes and dementia. A facility acuity interview conducted 10/16/23 revealed Resident 1 was administered insulin injections by non-licensed staff. The non-licensed staff were delegated by Staff 23 (Agency RN) who was hired specifically for delegation. Resident 1's MARs from 10/01/23 through 10/16/23 and delegation records were reviewed and revealed the following: Resident 1's MARs noted insulin had been given by Staff 18 (MT) and Staff 22 (MT) on multiple occasions. On 10/18/23 documentation of the delegations for Resident 1 were requested. At 3:15 pm on 10/18/23, Staff 6 (Regional RN) provided delegation documentation as Staff 23 was no longer in the facility. Staff 6 stated when she initially asked Staff 23 for the documentation, Staff 23 stated it hadn't been done. Later that day, Staff 23 provided Staff 6 with the delegation documentation. Staff 6 talked with two of the MTs whose delegations were included. Both Staff 18 and Staff 22 stated to Staff 6 they had not seen the delegation form, and it was not their signatures on the form. Staff 6 said she was not sure about the other delegations, and they were being investigated. At the time of the survey the facility contracted with an LPN to administer insulin until the facility RN could complete delegations. The need to ensure staff who administered insulin injections were delegated and re-evaluated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings 2. Resident 7 moved into the facility in 10/2022 with diagnoses including type II diabetes and Wernicke's dementia. During the acuity interview on 10/16/23, Resident 7 was identified to be administered insulin injections by non-licensed staff. Review of the 10/01/23 to 10/19/23 insulin administration records and delegation records showed the following: * Staff 3 (Staffing Coordinator), Staff 11 (MT) and Staff 24 (MT), documented on the MAR they administered Resident 7's insulin injection on multiple occasions; and * There was no documented evidence of delegation for Staff 3, 11 and 24. On 10/19/20 at 1:20 pm, Staff 6 (Regional RN) confirmed Staff 3, 11 and 24 administered insulin injection to the resident and there was no documented evidence Staff 3, 11 and 24 were delegated for the resident's insulin administration task. On 10/20/20, 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 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations). They acknowledged the findings. During the survey, Staff 6 stated Staff 24 was no longer working in the facility and contracted with an LPN who would administer insulin to all residents who required insulin administration until the facility RN could complete delegations.

1. Currently any delegatable procedures are being done by the LPN or RN. The RN is working on completing the diabetic assessments. The RN will evaluate all med techs for competence and complete all delegation paperwork. 2. The RN consultant will provide RN delegation forms and training to the community RN on RN delegation. The RN delegation binder will be re-organized and will have the necessary resources for the med tech. 3. Weekly, Monthly. 4. RN and Administrator.

Based on observation, interview and record review, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment and to comply with a qualified designated Infection Control Specialist and completed specialized training in infection prevention and control protocols within three months of being designated. Findings include, but are not limited to: 1. Resident 2 was observed eating lunch from 12:10 pm until 12:45 pm on 10/17/23 and breakfast from 8:20 am to 9:14 am on 10/18/23. S/he used his/her fingers to pick up all food, including meat, vegetables and scrambled eggs. The resident was observed frequently putting his/her fingers in his/her mouth as well as wiping his/her hands on his/her pants. Care staff observed in the dining room at the time of breakfast and lunch did not wash the resident's hands prior to meal services and following the meal. The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents, was discussed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/18/23 and 10/20/23. The findings were acknowledged. 2. Upon entrance to the facility on 10/16/23, the facility's designated Infection Control Specialist and documentation of completed specialized training in infection prevention was requested. No information was provided. During the survey on 10/18/23, Staff 2 (RCC) reported Staff 4 (Environmental Services Director) was the facility's designated Infection Control Specialist. On 10/19/23 at 8:20 am, survey team received the documentation of the facility's designated Infection Control Specialist completed specialized training in infection prevention. The documentation showed the training was completed on 10/18/23. On 10/20/23 at 9:30 am, Staff 1 (ED) stated the facility's designated Infection Control Specialist, Staff 4, did not have a health professional education background or experience in infection control or in health inspector. Staff 1 confirmed the facility's designated Infection Control Specialist completed the required training during the survey. The need to ensure establishment and maintenance of infection prevention control protocols and compliance with the facility's designated Infection Control Specialist qualification and completed required training in a timely manner was discussed with Staff 1, Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23 at 9:30 am. They acknowledged the findings and no further information was provided.

1. Care staff have been educated to assist residents with hand washing before and after meals. The LPN has been assigned the Infection Control Specialist role and will complete the Infection Control Specialist training on OCP. 2. Hand washing/hygeine to be taught to all staff at next staff meeting. This will include the importance of hand washing/hygeine for residents also. The LPN will complete the OCP Infection Control Specialist Training. 3. Monthly, Quarterly. 4. Nursing and Administrator

2. Resident 1 was admitted to the facility in 09/2018 with diagnoses including diabetes and dementia. A review of the 10/01/23 through 10/16/23 MAR and current physician's orders revealed the following: Resident 1 had a physician order for Novolog, give 5 units in the morning and evening with meals and give 8 units every day at noon with meal. Hold for CBG less than 100. On two occasions, 10/11/23 at 12:00 pm and 10/16/23 at 8:00 am, the medication was given outside the parameters when it should have been held. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 5 (RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure insulin orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 7) whose insulin orders were reviewed. Findings include, but are not limited to: 1. Resident 7 moved into the facility in 10/2022 with diagnoses including type II diabetes and Wernicke's dementia. The resident's insulin administration records dated 09/01/23 through 10/16/23 and physician orders were reviewed and revealed the following: Resident 7's current physician orders included: * Check CBG three times daily; and * To administer 6 units of Aspart insulin with each meal and based on the resident's CBGs additionally; : 0 - 149 = 0 unit : 150 - 199 = 6 units : 200 - 249 = 8 units : 250 - 299 = 10 units : 300 - 349 = 14 units : 350 - 399 = 16 units : 400 - 499 = 18 units : 500 - 600 = 20 units The 10/01/23 - 10/17/23 insulin administration records was reviewed. The records showed staff documented the resident's CBG results, a range of 153 to 507 daily. However, there was no documented evidence additional sliding scale insulin was administered to the resident. On 10/19/23 at 3:20 pm, the surveyor reviewed insulin administration records and physician orders with Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations). They confirmed there was no verification the correct amount of insulin was administered to Resident 7. The need to ensure physician orders were carried out as prescribed and documented was discussed with Staff 1 (ED), Staff 5, Staff 6 and Staff 7 on 10/20/23. They acknowledged the findings.

1. Resident 7's sliding scale insulin is now separate from the fixed dose that is given at each meal. Resident 1 has clear parameters in place to ensure insulin is being held appropriately. LPN and RN are currently administering insulin. 2. RN will audit insulin orders with each initial delegation, subsequesnt re-evaluations, and with any insulin changes. New orders will be reviewed during the clinical meeting for MAR accuracy. 3. Daily, Quarterly, and as needed 4. RN and Administrator.

Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 1 of 1 sampled resident (#16) whose orders were reviewed. Findings include, but are not limited to: Resident 16 was admitted to the facility in 10/2024 with diagnoses including depression with psychotic features, generalized anxiety, left-side affected stroke, and vascular dementia. Review of the resident's medical record, current physician orders, and MAR, dated from 11/01/24 through 12/10/24, revealed the following: Resident was hospitalized from 11/25/24 through 11/27/24, discharge instructions dated 11/27/24 contained the following orders: * Hydrocodone-acetaminophen 5-325 mg: Take one to two tablets by mouth every four hours as needed for pain for up to seven days; * Oxycodone-acetaminophen 5-325 mg: Take one tablet by mouth every four hours as needed for pain for up to 16 doses; and * Morphine ER 15 mg 12 hour tablet: Take 15 mg by mouth two times daily. There was no documented evidence oxycodone-acetaminophen 5-325 mg and morphine ER 15 mg were available for administration. The facility administered oxycodone on 11/27/24 and 11/28/24 to control pain. However, the facility did not have a current order for administration of oxycodone during that time. In an interview on 12/11/24 at 9:44 am, Staff 11 (MT) stated "Only oxy [oxycodone] was available [for administration] on the MAR". The hydrocodone-acetaminophen 5-325 mg was approved for dispensing by the MT on 12/01/24. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 26 (ED) and Witness 1 (Consultant RN) on 12/11/24. They acknowledged the findings.

1. Resident 16's 90 day orders were reviewed and sent to the PCP for review and signature.  The morphine order has been discontinued. 2. The nursing department will train and evaluate competence for all med techs in the 3-check system for processing orders. In the moment training will occur when an issue is identified related to order review. The nursing department will provide education with med techs on how to complete a MAR reconcilication when a care transition occurs. Nurses will review their own medication reconciliation with each care transition. A review of medication exceptions and variances will be completed during the daily clinical meeting with follow up the same day. LPN, RN, and the Adminstrator will complete the NurseLearn course "Managing Care Transitions." 3. Daily, Weekly 4. Administrator, Nurses, RCC

Based on observation, interview and record review, it was determined the facility failed to develop a staffing plan as the results of the facility's acuity-based staffing tool (ABST). Findings include, but are not limited to: The facility had 64 residents at the time of survey and consisted of four cottages. The facility's posted staffing plan revealed the following: * 2 Caregivers and 1 Medication Aide from 6:00 am to 6:00 pm in each cottage; and * 1 Caregiver and 1 Medication Aide from 6:00 pm to 6:00 am in each cottage. The facility's ABST was reviewed on 10/18/23 at 1:45 pm and discussed with Staff 2 (RCC). Staff 2 reported the facility used "Frontier Acuity Tool" and planned the staffing level based on the acuity tool. Staff 2 stated the facility updated the staffing plan weekly. However, Staff 2 reported the facility was not able to staff at the staffing level as the facility acuity tool indicated. Staff 2 stated the facility acuity tool indicated the facility required 2 CGs and 1 MA in each cottage and 2 CGs and 1 MA, floating between cottages from 6:00 am to 6:00 pm. During the survey, the facility staffing levels in each cottage revealed the following: * 10/16/23 from 6:00 am to 6:00 pm, 1 CG and 1 MA in Cottage A, 1 CG in Cottage B and C, and 1 MA floating between Cottage B and C; * 10/17/23 from 6:00 am to 6:00 pm, 1 CG and 1 MA in Cottage A, 1 CG in Cottage B and C, 1 MA floating between Cottage B and C, and 3 CGs including 2 trainees and 1 MA in Cottage D; and * 10/18/23 from 12:00 pm to 6:00 pm, 2 CGs and 1 MA in Cottage A and B, 3 CGs including 1 trainee and 2 MAs including 1 trainee in Cottage C, and 3 CGs including 2 trainees and 1 MA floating between Cottage D and other Cottage. The need to ensure the facility developed a staffing plan as the results of the facility acuity-based staffing tool was discussed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.

1. The community is actively recruiting for care staff positions and are utilizing agency staff until adequate staff is hired. 2. The ABST will be updated with quarterly service plan updates, with each new admission and with change of condiiton as the service plans are updated. Agency staffing will continue until enough care staff hired. The ABST will be reviewed by the administrator for accuracy. 3. Weekly, Monthly. 4. RCC, Administrator

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool to determine appropriate staffing levels. This is a repeat citation. Findings include, but are not limited to: On 06/11/24 at 12:25 pm, Staff 25 (Acting ED) reported the facility was under a new management company as of 06/01/24. She indicated they had been using a proprietary ABST with their former management company. Staff 25 stated she printed the ABST data on 06/02/24 and would provide a copy. She reported she would be entering the ABST data into the new management company's proprietary ABST soon. On 06/12/24, Staff 25 reported she was unable to find the printed copy of the previously-used ABST and that she did not yet have access to the new management company's ABST to input resident data. The need to implement an acuity-based staffing tool and determine staffing levels from the data was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 2 (Consultant RN) on 06/12/24. They acknowledged the findings.

1.)  Executive Director has been granted access to Oregon state ABST tool and ABST has been updated for facility. 2.)  The ABST will continue to be updated with quarterly service plan updates, new admissions and change of conditions.   3.)  Weekly, Monthly 4.)  Scheduler, Executive Director, Assistant Executive Director

Based on observation, interview, and record review, it was determined the facility failed to ensure all residents were entered into the staffing tool and to use the results of the tool to develop and routinely update the facility's staffing plan. This is a repeat citation. Findings include, but are not limited to: The facilities acuity-based staffing tool (ABST) was reviewed on 09/11/24 and the following was identified: * Not all current residents were entered into the tool; * Multiple former/past residents were still noted in the tool; and * A non-sampled resident receiving one-on-one staffing related to monitoring behavioral conditions or symptoms did not have the hours reflected in ABST. There were no staffing issues observed and resident needs were met. The need to ensure all residents were entered into the staffing tool, and potential inaccurate staffing calculations was discussed with Staff 26 (ED) on 09/11/24. She acknowledged the findings.

1.) ABST updated with all current residents, removed past residents, updated with correct hours for 1:1 resident. 2.)ABST will be updated with all service plan updates, new admission, discharges and change of conditions. 3.) Daily, weekly, Monthly 4.) Scheduler, Exectuive Director

Based on observation and interview, it was determined the facility failed to ensure storage was provided for all maintenance equipment and all chemicals and toxic materials were maintained in locked storage. Findings include, but are not limited to: On 10/16/23 at 1:50 pm, the surveyor conducted a walk-through of the facility and the following was observed: * An outdoor courtyard area contained miscellaneous maintenance equipment and supplies being stored outside; and * The soiled laundry room contained toxic chemicals and was unlocked/accessible. The need to ensure the facility provided storage for all maintenance equipment, and chemicals and toxic materials were secured in locked storage was discussed with Staff 4 (Environmental Services Director) on 10/18/23 at 9:45 am. He acknowledged the findings.

1. All outdoor maintenance equiment and supplies are now stored in locked storage. All toxic chemicals also stored in locked storage. 2. Scheduled walk throughs several times per week done by maitenance director and administrator. Staff trainign on ensuring laundry room remains locked and unaccessble to residents. 3. Weekly. 4. Maintenance Director and Administrator

Based on observation and interview, it was determined the facility failed to ensure interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: During a tour of the interior of the facility on 10/16/23 at 1:50 pm, carpet throughout the common area hallway and in the four cottages (A, B, C and D) was stained. The following doors were gouged and scraped: B8, C7 and C8. In the common area of B cottage a maroon recliner was observed to have stained/worn arms. The surveyor toured the environment with Staff 4 (Environmental Services Director) on 10/18/23 at 9:45 am. He acknowledged the findings.

1. Administrator is working to obtain quotes for carpet replacement. The doors for B8, C7, and C8 have been repaired and the recliner has been disposed. 2. Daily walk throughs by maintenance director and administrator. Staff will be trained to notify maintenance of repair needs. 3. Daily, Weekly 4. Maintenance director and Administrator

Based on observation and interview, it was determined the facility failed to ensure interior materials and surfaces were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to: During the survey, between 06/10/24 and 06/12/24, it was observed that much of the carpet in the facility had been replaced with vinyl flooring and that many of the resident units still had stained carpet. In an interview on 06/11/24 at 12:30 pm, Staff 4 (Environmental Services Director) reported they were not finished replacing all the carpet but were working on it slowly. On 06/12/24 at 12:40 pm, Staff 25 (Acting ED) reported they had been replacing the carpet with vinyl flooring in one resident room a month with their former management company. She stated the facility was under new management as of 06/01/24. When asked what the timeline was to complete the carpet replacement, she stated she was unsure what the new management company planned to do. The need to ensure interior surfaces were kept clean and in good repair was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 2 (Consultant RN) on 06/12/24. They acknowledged the findings.

1.)  Quotes have been obtained for replacement flooring and audit of rooms completed, starting with the rooms that need replacement first.  Rooms are still being kept clean while awaiting vinyl flooring in all resident rooms.   2.) Maintenance Director, Executive Director and Assistant Executive Director will continuing working on list of rooms to replace the flooring, currently replacing 2 rooms per month. 3.)  Daily, Weekly 4.)  Maintenance Director, Executive Director, Assistant Executive Director.

Based on observation and interview, it was determined the facility failed to ensure interior materials and surfaces were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to: During the survey, between 09/10/24 and 09/11/24, the carpets were observed to be soiled and stained in the following areas: *A cottage rooms 2, 5, 7, 8 , and 10; *B cottage rooms 1, 2, 3, 6, 7, and 9; *C cottage rooms 5, 8, 10, and 11; and *D cottage rooms 1, 4, 8, 10, and 11. The need to ensure interior surfaces were kept clean and in good repair was discussed with Staff 26 (ED) and Witness 2 (Consultant RN) on 09/11/24. They acknowledged the findings.

1.) Quotes for replacement have been obtained and audit of rooms completed. Rooms are being kept clean while awaiting vinyl flooring. 2.) Starting with cottage A in the back room 10 working forward, completing 2 rooms at a time. 3.) Daily, Weekly 4.) Maintenance Director, Executive Director

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 231, C 242, C 295, C 361, C 510 and C 513.

Refer to C 231, C 242, C 295, C 361, C 510 and C513.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 231, C 361, and C 513.

Refer to plan of corrections for C231, C260, C270,C361 and C513

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 152, C 200, C 231, C 361, and C 513.

Refer to plan of corrections for C152; C200; C231; C361 and C513

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 231, C 360 and C 362.

Refer to C231, C360 and C362

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 231 .

See POC for C 231

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

Refer to C 252, C 260, C 270, C 280, C 282 and C 303

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

Refer to plan of corrections for C231, C260, C270,C361 and C513

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

Refer to plan of corrections for C260 and C270

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 260, C 270, C 303, and C 310.

Refer to C260, C270, C303, and C310

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

See POC for C 260

Based on observation, interview and record review, it was determined the facility failed to ensure individualized nutritional plans for each resident were developed and included in service plans for 1 of 2 sampled residents (#6) whose service plans were reviewed for weight loss. Findings include, but are not limited to: Resident 6 was admitted to the MCC in 04/2022 with diagnoses including occipital lobe dementia and congestive heart failure. Observations made on 10/17/23 through 10/19/23, showed Resident 6 was dependent on staff for all ADLs and required hands-on assistance to eat meals. The resident had experienced severe weight loss over the past six months and was dependent on staff to meet nutrition and hydration needs. There was no individualized hydration and nutrition plan identified for the resident and the service plan lacked information and instructions on interventions to monitor for weight loss. The need to provide a daily meal program for nutrition and hydration based upon the resident's preferences and needs, available throughout each resident's waking hours and documented in the resident's service plan was discussed with Staff 1 (ED), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.

1. Resident 6 will have the individualized nutrition and hydration plan updated in service plan and communicated to staff. All service plans will be updated with individualized nutrition and hydration plans that will provide information on how to meet hydration needs, asssistance needed, and include interventions to maintain and monitor weight. 2. The consultant will provide training on how to service plan for nutrition and hydration and will review updated service plans. Nutrition and hydration plans will be included in the initial evaluation and service plan; updated with any changes and quarterly. 3. Quaterly and with change of condition. 4. RCC, Nurses, and Adminiatrator.

Based on observation, interview, and record review, it was determined the facility failed to evaluate each resident for activities and develop an individualized activity plan for each resident based on the activity evaluation for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose activity plans were reviewed. Findings include, but are not limited to: During the survey, many residents were observed needing assistance and encouragement from staff to initiate, attend, and participate in activities. The facility offered a couple of group activities including morning exercise and packing candies which a few residents attended in cottages A, B, and C. There was no other group or individual activities in cottages A, B, C and D. Majority of residents did not attend the activities and instead stayed in their rooms or walked around the facility. All residents were diagnosed with some type of dementia. The activity section of Resident 1, 2, 3, 4, 5 and 6's current service plans were reviewed. Though there was some information about each resident's past or current interests, the facility had not fully evaluated the residents': * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for participation; and * Activities that could be used as behavioral interventions. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with individualized activities. There were no instructions for providing activities for residents who did not participate in group activities. The need to develop individualized activity plans which were based on a thorough evaluation of the resident's interests, abilities and needs was discussed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.

1. Residents 1, 2, 3, 4, 5, & 6 evaluations will be updated to include all necessary components and service plans updated to include all required elements. All service plans will be updated with individualized activity plans. 2. Individual activity plans will be included in the initial and quarterly service plan. 3. Quarterly and with change of condition. 4. Marketing director or assigned caregiver until activity director hired. RCC and administrator.

Based on observation, interview, and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation, for 2 of 3 sampled residents (#s 15 and 17) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 15's and 17's records were reviewed and observations were made during the survey. The current activity evaluations did not address one or more of the following required components: * Current abilities and skills; and * Emotional/social needs and patterns. The current activity plans were not individualized to each resident based on their activity evaluation and not included on the resident's activity service or care plan. In an interview with Staff 33 (Lifestyle Director) on 12/10/24 at approximately 3:15 pm, she confirmed that the residents did not have an individualized activity plan included on their service plans. The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 33 on 12/10/24 and with Staff 26 (ED), Staff 36 (LPN Assistant Health Services Director), Staff 37 (RN Health Services Director), and Witness 1 (Consultant RN) on 12/11/24 at 9:39 am. They acknowledged the findings.

1. Resident 15 and 17 activity evaluations have been updated to address current abilities and skills, and emotional/social needs and patterns. 2. The Activity Director has updated the life enrichment form to include emotional and social needs and patterns related to activities. The Activity Director will review and update all residents indvidual activity plans. 3. Weekly, Monthly, Quarterly 4. Administrator, Activity Director

Based on observation, 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 4, 9, 19, and 20) whose records were review. This is a repeat citation, Findings include but are not limited to: Resident 4, 9, 19, and 20 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. Resident 4 was identified as not always being able to verbalize his/her needs. On 04/22/25, the resident was observed walking in a hallway with two staff members. Staff 11 (MT/CG) had one of the resident's favorite rock band's music playing on her phone. The resident showed signs of intently listening to the music, and when the chorus began, s/he sang along with perfect accuracy while smiling. This activity was not reflective in Resident 4's service plan. Resident 20 was observed to require staff assistance with escorting to activities and one-on-one meal assistance. The resident was in the common area most of the time without engaging in any group or 1:1 activities. On 04/22/25 approximately at 2:10 pm, the need to ensure the facility developed individualized activity plans based on the activity evaluation was discussed with Staff 43 (ED), Staff 44 (Consultant), Staff 45 (RN), Witness 1 (RN Consultant), and Witness 2 (RN Consultant). They acknowledged the findings.

1. Resident #9 no longer resides in the community. For residents 4, 19, 20, the community has updated the residents individual activity plans based on the activity evaluation. 2. All other residents will have an individual activity plan updated at their next quarterly review, change in condition, or move in. All other resident charts will be audited to ensure there is a current individual activity plan in place. Designated staff have received in depth training on individual service and activity plans.   3. Random, individual activity plan review will be conducted monthly for 3 months to assure they are individualized and reflect resident's current status. 4. The Administrator will be responsible for assuring that individualized activity plans are monitored on-going.

2. Resident 2 moved into the MCC in 10/2023 with diagnoses including Alzheimer's disease. Review of the resident's 09/28/23 move-in evaluation indicated that at 3:00 pm, the resident "starts sundowner, tries to wander away." The resident had behaviors including "shaking, grabbing and pushing and curses". Staff documented "COPs were called on 9/20/23. Resident was trying [to] leave." There was no service plan for the resident. During an interview on 10/17/23 at 1:18 pm, Staff 20 (CG) confirmed there was no service plan for the resident. The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 5 (Health Services Director, RN), Staff 6 (Regional RN), Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impacted the resident and others in the community were evaluated and included on the service or care plan for 2 of 4 sampled residents (#s 2 and 4) who had challenging behaviors in the MCC. Findings include, but are not limited to: 1. Resident 4 was admitted to the MCC in 10/2022 with diagnoses including Wernicke's dementia and acute encephalopathy. Record review and observations made during the survey revealed Resident 4 frequently exhibited escalated verbal behavior including yelling at staff and residents when agitated and exhibited rocking back and forth. The current service plan, dated 07/25/23, lacked resident-specific information that informed staff of the specific behaviors of concern and lacked individualized interventions for staff to try when responding to the behaviors. The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 5 (Health Services Director, RN), and Staff 6 (Regional RN) on 10/20/23. They acknowledged the findings.

1. Resident 2 & 4 will have their service plans updated to include behavioral symptoms that negatively impact others in the community, including interventions. All resident service plans to be reviewed and updated for any behavioral symptoms and interventions. Consultant will provied training on how to add indivudualized interventions to the service plan and provide staff traingin to staff on how to implement the interventions. 2. Service plans will be reviewed to ensure they include behavioral symptoms and interventions. Service plans will be evaluated at each quarterly update and with change of condition. 3. Quarterly and with changes. 4. RCC, Nurses, Administrator

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance. Findings include, but are not limited to: During a tour of the facility grounds on 10/16/23, two exit doors leading to an outdoor courtyard area were locked. The exit doors remained locked throughout the first two days of the survey. On the third day of survey, the doors were unlocked. Interviews with staff during the survey confirmed they were unaware who had the ability to lock/unlock the courtyard doors and when they should be locked/unlocked. On 10/20/23 the need to provide access to secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (ED) and Staff 6 (Regional RN). They acknowledged the findings.

1. All care staff have a key that unlocks the courtyard. The Key to rooms also work for the courtyard. All staff have been retrained how and when to lock and unlock the doors. 2. RCC and Administrator walk throughs. 3. Daily 4. RCC and Administrator

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to: The MCC was toured on 10/17/23 at 1:50 pm. Resident rooms including, but not limited to A3a, A6, A10b, B7a, C7a/b, C9a, C10a/b, D2a, D4b, D9b and D11b lacked any means of identifying the room for the resident. The need to ensure each resident room was identified to assist the resident in identifying their room was reviewed with Staff 1 (ED) and Staff 6 (Regional RN) on 10/20/23. They acknowledged the findings.

1. Marketing director is currently working on getting placards up with identifying information to help residents identify their apartment. 2. Administrator and activity director (once hired) walk throughs. 3. Daily, weekly 4. Administrator, Marketing director until activity director is hired.

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. In an interview with caregiving staff on 09/10/24 and 09/11/24, they explained resident room doors were all routinely locked to prevent wandering residents from entering. The need to ensure residents were not locked outside their rooms was discussed with Staff 26 (ED). She acknowledged the findings.

1.) All resident rooms that were locked were immediately unlocked. 2.) Staff educated regarding not locking residents out of their room even if it was done out of precautionary measure for wandering. 3.) Daily, Weekly, Monthly 4.) Executive Director

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 available for inspection. Findings include, but are not limited to: A tour of the facility conducted on 09/10/24 identified the Ombudsman Notification Poster was not posted in a location routinely accessible to residents. The need to ensure all required postings were in an accessible and conspicuous location for residents was discussed with Staff 26 (ED). on 09/11/24. She acknowledged the findings.

1.) Ombudsmen poster placed in resident cooridor by RCC office. 2.) Daily rounds are being conducted to ensure Ombudsmen poster stays in desired location. 3.) Daily 4.) Executive Director, LPN

Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that promoted privacy, respect, and dignity in a homelike environment. Findings include, but are not limited to: The community was toured on 09/10/24 through 09/11/24. The facility was comprised of four cottages. Two cottages with 10 units and two cottages with 12 units. Of the 44 units, 40 were double occupancy. The double occupancy units were observed and noted to be without a privacy curtain or screen of any kind. The lack of privacy for residents residing in shared apartments was reviewed with Staff 26 (ED) and Witness 2 (RN Consultant) on 09/11/24. They acknowledged the lack of privacy.

1.) 40 double occupancy units inventoried, quotes for ceiling track and curtains submitted for all double occupancy rooms. 2.) Education on resident rights provided to all staff. Plan for double occupancy rooms to have partitions placed, beginning in cottage A, then B, then C, then D.  Ensuring all double occupany rooms will recive curtains for privacy 3.) Daily, weekly 4.) Executive Director, Administrator

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 2 of 2 sampled residents (#s 16 and 17) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 17 was admitted to the facility in 04/2024 with diagnoses including dementia. The resident's 12/01/24 through 12/09/24 MAR was reviewed and the following was identified: The following PRN medications prescribed for agitation related to dementia lacked instructions for sequential order of use:   * Quetiapine; and * Haloperidol. The need to ensure the resident's MAR was accurate and included resident-specific instructions for PRN medications was discussed with Staff 26 (ED), Staff 36 (LPN Assistant Health Services Director), Staff 37 (RN Health Services Director), and Witness 1 (Consultant RN) on 12/11/24 at 9:39 am. They acknowledged the findings. 2. Resident 16 was admitted to the facility in 10/2024 with diagnoses including depression with psychotic features, generalized anxiety, left-side affected stroke, and vascular dementia. Resident 16's MARs from 11/01/24 through 12/10/24 and physician orders were reviewed, and revealed the following: a. The following PRN medications lacked instructions for sequential order of use:   * Acetaminophen 325 mg (for pain); * Diclofenac 1% gel 50 gm (for pain); and * Oxycodone 5mg (for pain). b. The following PRN medications lacked resident specific parameters for use: * Albuterol 90 mcg inhaler (for wheezing); and * Hydroxyzine 25 mg (for anxiety). The need to ensure the MAR was accurate and included resident-specific parameters and instructions for PRN medications was reviewed with Staff 26 (ED) and Witness 1 (Consultant RN) on 12/11/24. They acknowledged the findings.

1. PRN parameters are complete for resident 16 and 17. PRN parameters will be reviewed for all residents and updated as needed. 2. An audit of all orders will be completed by Consonous pharmacy. A review will be conducted of all residents to ensure 90-day orders are current. The Nursing team will complete a medication reconciliation with any transition of care/return to community. A review of medication exceptions and variances will be completed during the daily clinical meeting with same day follow up. 90-day orders will be reviewed with quarterly with the service plans. 3. Daily, Quarterly 4.) Administrator, Nurses

Based on observation, interview, and record review, it was determined the facility failed to ensure they had been consistently staffing to the posted staffing plan. Findings include, but are not limited to: The facility's Acuity Based Staffing Tool (ABST) entries, staff schedule, calculated staffing hours, and posted staffing plan were reviewed with Staff 26 (ED) and Witness 1 (Consultant RN). The facility posted staffing plan was as follows: * The facility operated on 12 hours shifts, running from 6:00 am to 6:00 pm; * 6:00 am to 6:00 pm: One CG and one MT in Cottage A and B and two CGs and one MT Cottage C and D; and * 6:00 pm to 6:00 am: One CG in Cottage A, one CG and one MT in Cottage B, two CGs Cottage D, and two CGs and one MT in Cottage C. The staff schedule, dated 12/04/24 through 12/10/24, was reviewed. On 12 out of 14 occasions, the number of MTs that worked did not meet the posted staffing plan and on seven out of 14 occasions, the number of CGs that worked did not meet the posted staffing plan. On 12/10/24 at 12:02 pm, Staff 26 reported staffing had been challenging over the past two weeks, particularly from Sunday to Wednesday, and the facility was unable to meet the required staffing levels during that period. On 12/10/24, an anonymous staff member reported s/he could not always pick up the morning or afternoon snacks from the kitchen for the residents as s/he was alone on the unit. The need to ensure the facility staffing plan and staff working on the floor exceeded the ABST staffing calculations and that the posted staffing plan matched the current staffing plan was discussed with Staff 26 and Witness 1 on 12/11/24 at 9:09 am. They acknowledged the findings.

1.) Staff recruitment is ongoing. ABST is updated multiple times per week with resident change of condition and service plan updates. 2.) The community is contracted with a recuriter to assist with the identification of potential employees. Additional agency contracts will be secured. 3.) Weekly 4.) Administrator, Staffing Coordinator

Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 1 of 3 sampled residents (# 17) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to: Resident 17 was admitted to the facility in 04/2024 with diagnoses including dementia. The resident's service plan, Interim Service Plans, ABST, and Charting Notes, dated 11/09/24 through 12/09/24, were reviewed. Staff were interviewed and Resident 17 was observed. The resident's ABST was reviewed and was not reflective of care time needed in the following areas: * Safety checks and fall prevention; * Monitoring behavioral conditions or symptoms; * Non-drug interventions for behaviors; * Repositioning in bed; and * Bowel and bladder management. The need to accurately capture care time on the resident's ABST was discussed with Staff 26 (ED), Staff 36 (LPN Assistant Health Services Director), Staff 37 (RN Health Services Director), and Witness 1 (Consultant RN) on 12/11/24 at 9:39 am. They acknowledged the findings.

1. Resident 17 ABST time was updated in ABST.  All residents ABST time has been updated concurrent with service plan updates. 2. Continued updates of the ABST multiple times per week. 3. Daily, Weekly 4. Administrator, Staffing Coordinator

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 231, C 260, C 270, C 361, and C 513.

Refer to plan of corrections for C231, C260, C270,C361 and C513

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 231, C 260, C 270, C 361, and C 513.

Refer to plan of corrections for C231; C260; C270; C361; and C513

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 231 , C 260 , C 270 .

Refer to C231, C260 and C270

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 231, C 260, and Z 164.

See POC for C 231, C 260, Z 164

Based on observation and interview, it was determined the facility failed to ensure residents rights of privacy in his or her own unit for multiple sampled and unsampled residents. Findings include, but are not limited to: Refer to C 200.

Refer to plan of correction for C200

Based on record review and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to: Review of records for Residents 12, 13, and 14 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms. Interviews with care staff on 09/10/24 and 09/11/24 identified residents were not provided keys to there rooms. The need to ensure all residents were provided keys to their units was discussed with Staff 26 (ED) on 09/11/24. She acknowledged the findings.

1.) Residents 12, 13 and 14 service plans were updated regarding keys hung in their apartment. 2.) Executive Director and nursing team updated all service plans for all residents. All residents will be given an apartment key and have it accessible. 3.) Daily, Weekly, Monthly 4.) Executive Director, Maintenance Director

The findings of the re-licensure survey, conducted 10/16/23 through 10/20/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily 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 survey to the re-licensure survey on 10/20/23, conducted 06/10/24 through 06/12/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with 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 second re-visit to the re-licensure survey of 10/20/23, conducted 09/10/24 through 09/11/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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 third re-visit to the re-licensure survey of 10/20/23, conducted 12/09/24 through 12/11/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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 fourth re-visit to the re-licensure survey of 10/20/23, conducted 04/21/25 through 04/22/25, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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

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 04/26/2023.  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

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 8/17/2022.  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