Brookdale Geary Street Memory Care

Based on observation and interview, it was determined the licensee failed to ensure adequate administrative oversight of facility operations regarding kitchen sanitation practices, which posed a risk to the safety of residents. Findings include, but are not limited to:

During the annual kitchen inspection, conducted 11/17/25 through 11/20/25, administrative oversight to ensure adequate food sanitation practices in the facility kitchen was found to be ineffective based on the severity of the citation.

1. A situation was identified where there was a failure of the facility to comply with the Department’s rules that was likely to cause residents serious harm. An immediate plan of correction was requested on 11/17/25 at 12:00 pm in the following areas:



OAR 411-054-0030 Resident Services, Meals, Food Sanitation Rule.



The facility provided a plan of correction on 11/17/25 at 2:24 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system(s) failure(s) associated with the licensing violation.

2. Refer to C240.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. The facility’s kitchen was observed in an unsanitary condition, with a person in charge without adequate knowledge or training, with multiple failed food safety practices which posed an immediate jeopardy situation that could threaten the health, safety, and/or welfare of residents. Findings include, but are not limited to:



Observations of the ALF facility kitchen which prepares all of the facility’s meals and the lunch meal service were completed on 11/17/25 from 10:10 am through 2:30 pm, and the following was identified:



a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black matter was visible on or underneath the following:



* Kitchen entrance threshold floor;

* Stainless steel prep tables;

* Stainless steel open shelving;

* Interior and exterior of ice machine;

* Ice machine scoop holder;

* Juice machine area by nozzles;

* Top of beverage dispensers;

* Utility carts;

* Hand washing sink;

* Stainless steel shelving above hand washing sink;

* Legs of prep tables;

* Walls and floors throughout kitchen;

* All kitchen drains;

* Shelving under the steam table;

* Interior and exterior of cabinets storing clean dishes;

* Steam table wells;

* Faucet and handles of prep sink;

* Interior and exterior of temperature regulated/insulated carts;

* Walk-in cooler floors under metal shelving and in thresholds;

* Walk-in cooler metal racks;

* Walls in walk-in cooler;

* Interior of plastic bin storing fruit and vegetables;

* Removable metal racks in walk-in cooler;

* Fan cages of walk-in cooler and freezer;

* Celling and sprinkler head in walk-in cooler;

* Interior and exterior of microwave, convection ovens, and industrial steamer;

* Removable hood vents;

* Piping/electrical conduit by oven and wall;

* Stove top burner plates;

* Knobs and handles of stove and grill;

* Industrial can opener and housing;

* Industrial mixer;

* Stainless steel table where mixer was located;

* Interiors and exteriors of stainless steel drawers throughout kitchen;

* Outsides, lids and handles of trash cans;

* Windowsills and screens;

* Vents and light fixtures;

* White food bin exteriors;

* Floors in dry storage;

* Oven mitts;

* Interior of clear plastic bin storing clean cooking utensils;

* Knife holder attached to knives (knives and holder);

* Sanitizer dispenser; and

* Sides of steam line cabinets.



b. The following areas were in need of repair:



* A section of wall by the entry to the kitchen threshold was damaged near floor.

* Caulking behind the three-compartment sink had black matter build-up and was in need of replacement.

* Multiple areas in tile floor had missing grout;



c. Scoops and spoons were observed in bulk food containers with handles touching food surfaces.



d. Multiple kitchen staff were observed preparing food and/or handling clean dishes without appropriate facial hair restraints as required. Staff 2 (Dining Services Director) had visibly soiled and very dirty outer clothing. Staff 2 was observed to wipe his hands on his outer clothing multiple times during the review.



e. Staff 2 was interviewed regarding how often sanitizer buckets were changed and he indicated every four hours, not every two hours or as needed per rule.



f. The handwashing sink did not have paper towels to properly dry hands. Facility staff were not able to state when the dispenser had run out of towels. The hand washing sink also had visible debris inside the sink indicating was used for purposes other than hand washing.



g. Multiple kitchen staff, including Staff 2, were not observed washing hands as required. This included times where hands were contaminated from touching clothing, other surfaces, and/or handles.



h. Multiple food items were observed stored in dry storage, walk-in cooler and/or freezer that were not closed or covered and were exposed to potential contamination.



i. A large container of used/dirty/rancid oil was observed stored uncovered under a shelf in the back food prep area. The facility did not have a system to correctly dispose of used cooking oil. Staff 2 indicated that bucket had been there for at least 2-3 months.



j. A trash can without a liner and with visible food debris was observed stored in the dry food storage area.



k. Staff 2 was preparing a ground beef product for lunch. The product was placed into the steam well without checking the temperature to ensure it had reached 155 degrees F for 15 seconds. Surveyors intervened and asked Staff 2 to check the temperature. It was found ranging between 140-145 degrees F. Staff 2 indicated they often put the products in about 10 degrees under to finish cooking in the steam wells. Surveyors indicated food for service must be fully cooked prior to placement in the steam wells and that food should not be “cooked” in the steam tables. Staff 2 also was not aware that ground beef could not be served at a medium doneness and must be fully cooked (155 degrees F or higher).



l. Staff 2 was observed to check food temperatures with a thermometer that was not at a fully cooked temperature and did not sanitize thermometer prior to checking temperatures of fully cooked product, potentially contaminating the fully cooked product. Staff 2 was not observed to sanitize thermometer before, between products, or after use before storing probe in protective cover.



m. Multiple kitchen towels were observed stored in various places throughout the kitchen, not in the sanitizer buckets as required. Several were visibly soiled and stiff. Staff 2 was observed to wipe his hands with a kitchen towel without observation of appropriate hand hygiene measures.



n. Boxes of food product were observed stored on the floor of the walk-in freezer. In an interview, Staff 2 confirmed the facility had received stock more than 24 hours prior.



o. Multiple cutting boards were found heavily scored or stained and in need of replacement. Multiple oven/hot mitts were found damaged with holes and rips.



p. Staff 2 was not able to demonstrate knowledge in cleaning practices, effective hygiene practices, effective sanitation practices, correct cooking practices, proper cooling practices, appropriate cold and dry food storage practice, or proper reheating processes.



In an interview on 11/17/25 at approximately 12:00 pm, Staff 1 (Executive Director) and Staff 3 (Associate Executive Director) was informed by the Surveyors of the significant sanitation and safety concerns, and that the kitchen would be shut down. The facility was instructed to submit an immediate plan of correction to address the unsanitary and unsafe conditions. Staff 1 had toured the kitchen area with the surveyors and had observed and acknowledged the areas identified and in need of immediate attention/correction.



An immediate plan of correction to address the deficient kitchen sanitation practices was requested on 11/17/25 at 12:00 pm. The facility provided a plan of correction on 11/17/25 at 2:24 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system(s) failure(s) associated with the licensing violation.



On 11/20/25 at 10:15 am, the surveyors returned to inspect progress of addressing sanitation and poor repair concerns. Surveyors toured areas with Staff 4 (District Director of Operations), Staff 5 (Traveling Dining Services Specialist). Staff 4 and Staff 1 outlined the ongoing training plan for the Person-In Charge and the ongoing oversight of the food service operations. The facility also outlined the plan for a consultation from a Registered Dietitian at least quarterly for an extended amount of time to ensure on going compliance. Facility acknowledged lack of adequate staff for kitchen was a contributing factor to poor sanitation. At that time, it was determined the facility could safely resume food service operations.

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

Refer to C240.

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

During the annual kitchen survey, conducted 12/24/24, quality improvement oversight was found to be inadequate to ensure the facility's dining services were maintained in a safe and sanitary condition, following Oregon food code practices and menus as outlined in rule.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the facility kitchen was completed on 12/27/24 from 10:30 am through 2:30 pm and the following was identified:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:

* Floors throughout kitchen;
* Floors in the dining room;
* Walk in cooler floors under metal shelving and in thresholds;
* Walls throughout kitchen behind prep areas;
* Open shelving throughout kitchen;
* Interior and exterior of microwave;
* Interior and exterior of convection ovens;
* Industrial can opener and housing;
* Industrial mixer;
* Door thresholds with food debris/splatter;
* Interiors and exteriors of stainless steal drawers;
* Go racks stored in walk in;
* Metal racks in walk in cooler and freezer;
* Outsides and handles of trash cans;
* Small appliances (blender/robot coupe);
* Windowsills and screens;
* Vents and light fixtures;
* White food bin exteriors;
* Utility carts;
* Dish washing rack dolly/cart;
* Interior and exterior of food transportation carts;
* Clean area of dish washing station;
* Floors and walls in dish washing area;
* Kitchen drains; and
* Water cooler in dining room;

b. The following areas were in need of repair:

* Multiple ceramic tiles in threshold of walk in cooler and freezer with cracks;
* Multiple areas in dining room walls with missing, chipped or scrapped paint;
* The walk in freezer had a large accumulation of ice that was on cardboard boxes and had dripped/froze potentially contaminating food product in the cardboard boxes below the drip/freeze.

c. Scoops/spoons observed in bulk food containers with handles touching food surfaces.

d. Multiple potentially hazardous foods were found past 7 days from the original preparation date. A large container of chicken salad was dated 11/16/24 and was observed to have visible mold growth on the food product. Another container of tuna salad was dated 11/22/24 and was observed with visible signs of food decay/rot. A container of prepared sandwiches was noted dated 12/14/24, 14 days from preparation date.

e. Multiple food items found in walk in cooler noted without proper labels and/or dates when opened or prepared as required. Multiple items were found open and/or not covered/sealed appropriately to protect from potential contamination.

f. Multiple kitchen staff were observed preparing food and/or handling clean dishes without appropriate facial hair restraints as required.

g. A kitchen employee was observed to have on plastic gloves underneath visibly heavily soiled rubber gloves washing dishes. The staff removed the soiled gloves and handled clean dishes with the visible wet plastic gloves on underneath the soiled rubber gloves. No hand hygiene step was observed between dirty and clean tasks as required.

h. A container of hot sauce, a visible dirty metal baking supply, and a to-go coffee cup was observed on the clean side of the dish machine potentially contaminating the clean area of the dish area. The coffee cup was an employee drink and did not contain the appropriate straw or handle as required.

i. The kitchen had four red surface sanitizing buckets. These buckets were tested for appropriate surface sanitizing levels. The facility was asked for test strip and a quat 10 strip provided. None of the four buckets registered any concentration of sanitizing solution. Staff 2 (Dining Services Coordinator) was asked to make a fresh bucket and test the solution. The chemical that came from the dispenser did not register any quat sanitation which is what staff 2 thought was the sanitizing chemical. When asked how frequent the buckets were changed staff 2 responded every 3-4 hrs not the every 2 hrs or as needed per rule. Facility indicated they would contact their Eco lab representative to check the dispenser as soon as possible.

j. The snack fridge on the unit did not contain a thermometer to ensure food was stored at the appropriate cold food storage temperature.

k. A week’s worth of menus was requested at the start of survey, Staff 2 indicated the facility did not currently have 7 days of menus in advance as required. Staff 2 stated they were working on developing the menus as required but was short staffed and had not been able to complete it. Staff 2 indicated they had to change the menu to use up food supply. Staff 2 was asked if residents were notified in advance when menu items changed. Staff 2 stated they did try to let them know if and when they could. Staff 1 (Executive Director) was interviewed and acknowledged the facility currently did not have a system for communicating menu changes with residents per guidelines.

At 12:00 pm, the memory care unit was observed and the following was items were noted in need of cleaning;
*interior and exteriors of reach in coolers;
* Dry cereal bins,
* Industrial can opener and housing;
* Walls, ceiling and vents in dish washing area with dust and/or splatter;
* Interior and exterior of microwave;
*Fan blades and cages;
* Pot holders;
* Top of Dish machine;
* Utility carts;
* Door seal of reach in freezer with black debris;
* Oven in dining room area with food spill debris;

The memory care kitchenette had multiple items in reach in cooler that did not have dates when opened or were passed 7 days from preparation dates including a package of hot dogs that were opened 10/22/24. There was a open can of energy drink in the food service area that did not have a lid or a straw and in approved area per rule.

Staff 2 (Dining Service Coordinator) toured kitchen areas with surveyor and acknowledged identified areas needing attention. At approximately 2:00 pm, surveyor reviewed above areas with Staff 1 (Executive Director), who acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

Refer to C240.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, conducted during a site visit on 12/17/24, the facility's failure to update an acuity-based staffing tool (ABST) was substantiated. Findings include, but are not limited to:A review of the facility's ABST and resident roster indicated all 30 residents were included in the tool and had a completed ABST evaluation.A review of the facility's ABST indicated the following:· The "minimum time needed based on acuity" on day shift was 5.76 direct care staff; on swing shift was 4.02 direct care staff; and night shift was 1.2 direct care staff.· Only 20 of 22 activities of daily living (ADL) had been addressed. A review of the facility's posted staffing plan indicated the following:· Day shift: Four caregivers and two med techs;· Swing shift: Three caregivers and one med tech; and· Night shift: Two caregivers and one med tech;A review of the facility's staff schedule and timecards dated 12/11/24 through 12/17/24, indicated the facility was consistently staffing to their posted staffing plan.A review of Resident 1 and Resident 2's records and ABST profile indicated no discrepancies. Staff 1 (Executive Director) indicated the following;· The facility used a proprietary ABST called PEAR. The tool had not been approved by the State. · One resident required one-on-one assistance. The facility had been scheduling additional staff to meet the need. · Five residents who had required two-person transfers.· The facility's ABST failed to separately list all 22 required ADL questions for each resident. · The facility ABST had only 20 of 22 required ADLs. CS observed day shift was staffed with five caregivers and two med techs. It was determined the facility failed to update an acuity-based staffing tool. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

Based on observation, interview, and record review, conducted during a site visit on 12/17/24, the facility's failure to update an acuity-based staffing tool (ABST) was substantiated. Findings include, but are not limited to:A review of the facility's ABST and resident roster indicated all 30 residents were included in the tool and had a completed ABST evaluation.A review of the facility's ABST indicated the following:· The "minimum time needed based on acuity" on day shift was 5.76 direct care staff; on swing shift was 4.02 direct care staff; and night shift was 1.2 direct care staff.· Only 20 of 22 activities of daily living (ADL) had been addressed. A review of the facility's posted staffing plan indicated the following:· Day shift: Four caregivers and two med techs;· Swing shift: Three caregivers and one med tech; and· Night shift: Two caregivers and one med tech;A review of the facility's staff schedule and timecards dated 12/11/24 through 12/17/24, indicated the facility was consistently staffing to their posted staffing plan.A review of Resident 1 and Resident 2's records and ABST profile indicated no discrepancies. Staff 1 (Executive Director) indicated the following;· The facility used a proprietary ABST called PEAR. The tool had not been approved by the State. · One resident required one-on-one assistance. The facility had been scheduling additional staff to meet the need. · Five residents who had required two-person transfers.· The facility's ABST failed to separately list all 22 required ADL questions for each resident. · The facility ABST had only 20 of 22 required ADLs. CS observed day shift was staffed with five caregivers and two med techs. It was determined the facility failed to update an acuity-based staffing tool. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

The findings of the re-licensure survey, conducted 04/29/24 through 05/03/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to Home and Community Based Services rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a dayA situation was identified where there was a failure of the facility to comply with the Department's rules which was likely to cause residents serious harm. An immediate plan of correction was requested in the following area:C282: OAR 411-054-0045 (1)(f)(B) RN Delegation and TeachingThe facility put an immediate plan of correction in place during the survey and the situation was abated.
The findings of the first re-visit to the re-licensure survey of 05/03/24, conducted 09/03/24 through 09/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second re-visit to the re-licensure survey of 09/04/24, conducted 04/10/25, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight for the operation of the facility and to ensure the quality of services rendered in the facility. Findings include, but are not limited to:During the relicensure survey, conducted 04/29/24 through 05/03/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity of the citations.1. A situation was identified which constituted an immediate threat to the health and safety of the residents in the following area:C282: OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching.The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety, and the situations were abated.2. Refer to deficiencies in the report.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings included, but are not limited to:During the survey, conducted 04/29/24 through 05/03/24, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.The need to ensure the facility developed and conducted an ongoing quality improvement program that evaluated services, resident outcome and satisfaction was discussed during the exit interview. No additional information was provided.Refer to the deficiencies in the report.

Based on interview and record review, it was determined the facility failed to investigate incidents to rule out abuse, document all required areas of an investigation, and/or immediately report to the local Seniors and People with Disabilities (SPD) office if abuse could not be ruled out for 4 of 4 sampled residents (#s 1, 2, 3, and 4 ) reviewed for resident-to-resident altercations and unwitnessed falls. Findings include, but are not limited to:1. Resident 1 moved into the facility in 11/2022 with diagnoses including dementia with behavioral disturbance. A review of the resident's 04/26/24 service plan, 01/29/24 through 04/29/24 progress notes and incident reports for the same time period were completed. Resident 1's service plan identified the resident as having recurrent aggressive and sexually inappropriate behaviors. A review of the resident's records identified the following: * On 01/30/24, progress notes and an incident report noted, "[Resident 1] was rubbing [another resident's] buttocks with [his/her] hand and [the other resident] was witnessed kissing [Resident 1] on [his/her] forehead."An investigation was completed but no report was made to the local SPD office until 02/07/24, eight days after the incident.* On 02/04/24, progress notes and an incident report noted that staff had found another resident lying in Resident 1's bed. Resident 1 was not wearing pants and was standing at the bedside. An investigation was completed, but no report was made to the local SPD office until 02/07/27, three days after the incident. * On 02/05/24, progress notes and an incident report noted, a resident-to-resident altercation in which Resident 1 had slapped another resident with an open hand. An investigation was completed, but no report was made to the local SPD office until 02/07/24, two days after the incident.In addition, the facility failed to ensure the above incidents had been reviewed by the administrator. The need to ensure incidents of abuse or suspected abuse were immediately reported to the local SPD office and promptly investigated was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.2. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance.A review of the resident's 04/03/24 service plan, 01/29/24 through 04/24/24 progress notes and incident reports for the same time period were completed. Resident 4's service plan identified the resident as having physical and verbally aggressive behaviors toward other residents and staff. A review of the resident's records showed the following:* On 02/25/24, staff documented in a progress note that Resident 4 had charged and screamed in another resident's face. "[Resident 4] slapped [the resident] in the face and was going to punch [him/her]." [Resident 4] picked up a chair and was going to throw it at [the resident]." * On 03/03/24, staff documented in a progress note Resident 4 was in a resident-to-resident altercation and had obtained a skin tear.Investigations were completed at the time of the incidents; however, the incidents were not reported to the local SPD office.The facility was directed to self-report the incidents to the local SPD office. Confirmation the reports had been sent was received on 05/03/24.The need to immediately report resident altercations to the local SPD office was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.
3. Resident 3 was admitted to the facility in February 2021 with diagnoses including dementia.Interview and record review revealed the following: * On 02/12/24, Resident 3 experienced an unwitnessed fall with an abrasion to his/her back. The incident was investigated, however, there was no documented evidence of an administrator review of the incident. * On 03/10/24, Resident 3 experienced an unwitnessed fall with fractured ribs. The incident was investigated, however, there was no documented evidence of an administrator review of the incident.On 05/03/24, the need to ensure investigations of suspected abuse were reviewed in a timely manner by the facility administrator was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations) Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings.
4. Resident 2 was admitted to the facility in 09/2016 with diagnoses including dementia.The resident's record, including progress notes and incident reports, was reviewed, and staff were interviewed. The following was identified:A progress note dated 03/05/24 indicated the resident was found on the floor in his/her room with "a laceration on the back of [resident's] head that was bleeding."Staff 1 (Associate Executive Director) confirmed in an interview on 05/03/24 that the incident report dated 03/05/24 did not include an investigation which ruled out abuse or neglect. The surveyor requested the facility report the incident to the local Seniors and People with Disabilities (SPD) office on 05/03/24. Confirmation was provided of the report prior to survey exit.The need to investigate unwitnessed falls with injury to rule out abuse and/or neglect, and to report the incident to the local SPD office if abuse and/or neglect could not be ruled out, was discussed with Staff 1, Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

2. Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes and dementia with behavioral disturbance. Resident 1's most recent quarterly service plan was updated 04/26/24. There was no documented evidence of a quarterly evaluation which corresponded with the 04/26/24 service plan update.In an interview on 05/02/24, Staff 4 (RN/Health and Wellness Director) reported that she had not completed the resident's quarterly evaluation.The need to ensure the facility completed resident evaluations quarterly was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.3. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance. Resident 4's most recent quarterly service plan was updated 04/03/24. There was no documented evidence of a quarterly evaluation which corresponded with the 04/03/24 service plan update.In an interview on 05/02/24, Staff 4 (RN/Health and Wellness Director) reported that she had not completed the resident's quarterly evaluation.The need to ensure the facility completed resident evaluations quarterly was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to complete quarterly evaluations for 4 of 4 sampled residents (#s 1, 2, 3, and 4), whose evaluations were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in February 2021 with diagnoses including dementia.Resident 3's most recent quarterly service plan was updated 12/28/23. There was no documented evidence of a quarterly evaluation which corresponded with the 12/28/23 service plan update.On 05/02/24, Staff 1 (Associate Executive Director) reported the service plan dated 12/28/23 was all she had related to a quarterly evaluation for Resident 3.On 05/03/24, the need to ensure a quarterly evaluation was completed timely was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings.
4. Resident 2 was admitted to the facility in 09/2016 with diagnoses including dementia. A review of the resident's record identified his/her quarterly evaluation had not been completed.Staff 4 (RN/Health and Wellness Director) confirmed in an interview on 05/02/24 that she had completed the resident's current service plan, dated 04/06/24, without completing a quarterly evaluation.The need to ensure resident evaluations were completed quarterly, was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans provided clear instructions to staff for 2 of 4 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes and dementia with behavioral disturbance. The resident's 04/26/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan failed to provide clear direction to staff in the following areas:* Frequency of supervision related to behaviors; and * Emergency evacuation ability. The need to ensure service plans included clear direction to staff was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.2. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance. The resident's 04/03/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan failed to provide clear direction to staff in the following areas:* Frequency of toileting assistance and brief changes;* Oral care and clear instructions on what staff were to complete;* Pain areas and treatment; and* Emergency evacuation ability.The need to ensure service plans included clear direction to staff was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 3 of 4 sampled residents (#s 1, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:Residents 1, 3, and 4's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of their service plans.On 05/03/24, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure interventions for changes of condition were determined, communicated to staff, and/or were monitored and evaluated for effectiveness for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced changes of condition related to skin, behaviors, and falls. Resident 1's wounds worsened. Findings include, but are not limited to:1. Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes and diabetic polyneuropathy. a. During the acuity interview on 04/29/24 and interviews with care staff between 04/29/24 and 05/02/24, staff indicated Resident 1 had wounds on both feet. A record review showed the resident's feet were treated by HH until 02/08/24. On 02/08/24, the HH RN left the following wound care recommendations for the facility: Washing the resident's feet at least every other day and apply vaseline or lotion. There was no documented evidence the facility washed the resident's feet every other day or applied lotion to the resident's feet. The facility failed to communicate those instructions to staff. The resident's 01/29/24 through 04/29/24 progress notes and skin documentation indicated the resident experienced the following changes of condition: On 02/14/24, staff documented in a progress note that the resident had a visit from a podiatrist. "Services performed: debridement of nails times ten with use of nail nippers and debulked with [the] use of a dremel. Nursing staff will continue to monitor [resident's] feet on a routine basis. Recommended routine debridement of nail plates at three-month intervals or sooner if any pathological problems occur with the feet. Recommended use of protective shoe gear to prevent incidental damage to the feet."On 03/17/24, staff documented in a progress note that the resident was found on the floor of his/her bedroom. "Staff noticed blood and found wounds on several toes that were bleeding." The resident was sent to the emergency room. Between 02/14/24 and 03/17/24 the facility failed to monitor and document on the progress of the wounds. On 03/23/24 staff documented in a progress note that the resident had fallen. The MT noted the following: "saw some blood from [his/her] feet and checked [his/her] toes and saw some sores and a new open area."On 03/27/24, staff documented in a progress note that the "resident has wounds on [his/her] left foot. Big toes [on left foot were] bleeding and had dry blood build up. MT has cleaned and disinfect. Ring toe is swollen, red and warm to the touch." It was further noted that staff were instructed by the facility RN to put socks and shoes on the resident. The resident was placed on alert charting.On 03/28/24, the RN completed a significant change of condition note related to wounds on toes. The RN noted the following: "[Resident 1] has developed open wounds on [his/her] 2nd, 3rd, and 4th toes on the dorsal aspect of both feet. [S/he] also has a closed, calloused wound on [his/her] right 2nd toe on the bottom. [His/her] big toes are in need of podiatrist nail care. [Resident 1] refuses to wear socks and the wounds are present in the area where [his/her] toes come into contact with the fabric of [his/her] shoes. [Resident 1] is reluctant to have any treatment done on [his/her] toes." The RN noted the resident was very resistant to showering or changing clothes and often slept with shoes on. The RN documented the resident was encouraged to wear socks and noted the resident seemed to understand that his/her shoes were rubbing on his/her toes. It was further noted that an evaluation by the resident's PCP was needed prior to a HH referral.On 04/23/24 the RN and LPN assessed the resident toes and documented the following: "Right foot 2nd toenail appears to have been pulled out some time ago, as the bed is hard and dark pink. There is an abrasion on the top of this toe, appx 0.8cm roughly round. This was cleaned with wound cleanser, dried and a band aid applied. There is a black, hard calloused area on the tip of the toe, slightly medial. 4th and 5th toes have hard scaly thickened areas, pale yellow and brown in color. Several areas of the toes have peeling, thick skin. Resident denies pain anywhere on his feet. Left foot has no open areas, but 3rd and 4th toes both have the same type of hard, scaly thickened areas on the tops and at the base of both. All toes have the peeling thick skin as well."Between 03/28/24 and 04/23/24 the facility failed to monitor the wounds consistent with the resident's evaluated needs and service plan.The RN documented on 04/10/24 and 04/23/24. The 04/23/24 note indicated the resident's sibling was called regarding the importance of the resident to be seen for his/her feet. The sibling had stated that the resident had an appointment on 04/25/24. On 04/25/24 a progress note documented the resident's sibling had transported the resident to an appointment at the Diabetes Care Clinic. It was noted the "diabetic nurse did nail clipping and wound debridement and had instructed the [sibling] to take [Resident 1] to Urgent Care." On 04/26/24 a progress note documented the resident's sibling had transported the resident to urgent care. The resident was diagnosed with an infection and was prescribed an antibiotic. The resident's wounds worsened, and subsequently developed into infection requiring antibiotics. The following deficiencies were identified:* The facility failed to evaluate and document the status of the wounds at the time they assumed wound care from HH. The facility also failed to monitor the progress of the wounds and evaluate the effectiveness of the interventions/treatments; * The facility failed to add the instructions regarding washing the resident's feet at least every other day and applying lotion to the service plan and communicate those instructions to staff; and * The facility failed to monitor the resident's wounds consistent with his/her evaluated needs and service plan. The facility's failure to update the resident's service plan with interventions, communicate to staff and monitor the progress of wounds, resulted in the wounds worsening and subsequently developed into an infection, was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.b. The resident's current service plan dated 4/26/24, Temporary Service Plans, progress notes dated 01/29/24 through 04/29/24 were reviewed. Interviews with care staff were completed between 04/29/24 and 05/02/24.The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution:02/16/24 - Sexual and aggressive behaviors; 03/17/24 - Fall with skin injuries; 03/23/24 - Fall with injury; and04/10/24 - Fall due to low blood sugar, resident was sent to the emergency room.On 05/03/24, the need to ensure resident specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored at least weekly, through resolution was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.2. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance.The resident's current service plan dated 04/03/24, Temporary Service Plans, progress notes dated 01/31/24 through 04/24/24 were reviewed. Interviews with caregivers were completed between 04/29/24 and 05/02/24.The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution:* 02/18/24 - Resident to staff physical altercation. The resident had fallen after hitting a staff member and was sent to the emergency room; * 02/25/24 - Resident to resident altercation; * 03/03/24 - Resident to resident altercation; and* 04/19/24 - Pain in right arm and excessive drooling. The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.
4. Resident 3 was admitted to the facility in February 2021 with diagnoses including dementia.Observations of the resident, interviews with staff, and review of the resident's clinical records, including incident reports, progress notes dated 01/30/24 through 04/29/24, service plan dated 12/28/23, and weight records was conducted.a. Record review indicated the resident experienced a 6.4 pound weight loss from 03/2024 to 04/2024 which constituted a severe 6.60% loss in one month.There was no documented evidence of ongoing monitoring of the resident's weight, no documentation the weight loss was reported to the RN and there were no interventions implemented.On 05/01/24, survey requested a current weight for Resident 3. The weight was noted as an increase of 2.6 pounds.On 05/01/24, the need to respond to significant/severe weight loss with ongoing monitoring, implementation of interventions and evaluation for effectiveness of those interventions was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), and Staff 4 (RN/Health and Wellness Director). They acknowledged the findings.Refer to C280.b. Resident 3's record was reviewed for changes of condition and the following falls with injury were identified:*On 02/12/24, Resident 3 was found on the floor of his/her bedroom with an abrasion near the middle of their spine. There was no evidence the facility monitored the short term change until resolution. *On 03/10/24, Resident 3 was found on the floor of his/her bedroom with complaints of pain to his/her right side. Staff documented in a progress note, on 03/10/24, the resident returned from the local hospital with four fractured ribs. While the facility implemented interventions after the fall, there was no documented evidence the facility monitored the resident consistent with his/her evaluated needs.On 05/03/24, the need to ensure the facility was monitoring short term changes of condition through resolution and significant change of condition with their evaluated needs was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings.
3. Resident 2 was admitted to the facility in 09/2016 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's clinical record including service plan dated 04/06/24, progress notes dated 02/01/24 through 04/23/24, and weight records was conducted.a. Weight records from 12/19/23 through 04/08/24, reviewed on 04/29/24 indicated the resident weighed:* 09/01/23: 129.0 lbs;* 09/08/23: 132.8 lbs;* 10/08/23: 121.2 lbs;* 12/19/23: 118.0 lbs;* 01/09/24: 124.8 lbs;* 03/01/24: 119.0 lbs; and* 04/08/24: 118.0 lbs.An RN assessment dated 03/05/24 noted a 13.8 pounds weight loss or 10.4% of his/her body weight. The assessment noted the following interventions: * Second helpings; and* Substitute calorie rich food if not interested in what s/he was served.There was no documented evidence the interventions were communicated to staff. On 05/02/24 Staff 4 (RN/Health and Wellness Director) reported she had filled out a temporary service plan for the interventions but did not know where it was. The current service plan dated 04/06/24 did not identify the interventions. On 04/29/24 Resident 2 was observed during lunch to eat 100% of his/her puree meal and was not offered seconds. On 04/30/24 Resident 2 was observed during lunch to eat 100% of his/her meal, was offered seconds, and was then observed to eat 100% of the 2nd entrée that was provided. A staff member asked Resident 2 if they would like more, to which the resident nodded and the staff confirmed, but no third helping was provided.In addition, staff initialed on the MAR they were administering a MightyShake nutrition supplement with meals however none was observed with lunch on 04/29/24 and 04/30/24. On 05/01/24 a current weight for Resident 2 was requested and provided, which identified the resident as continuing to lose weight, at 114.8 pounds. Between 04/08/24 and the time of the survey, 5/1/24, Resident 2 lost an additional 3.2 pounds.The need to ensure interventions for significant changes of condition were communicated to staff, and monitored consistent with the resident's evaluated needs, was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.b. The following short-term change of condition lacked documentation of progress noted at least weekly through resolution:* 03/05/24 - wound on back of head.The need to ensure short term changes of condition were monitored at least weekly through resolution was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a significant change of condition was assessed by an RN, with resident status documented, and interventions developed as a result of the assessment, for 1 of 3 sampled residents (#3) who experienced a significant change of condition. Findings include, but are not limited to:Resident 3 was admitted to the facility in February 2021 with diagnoses including dementia.Review of Resident 3's weight records from 11/2023 through 04/2024 showed the following:On 03/08/24, the resident weighed 95.6 pounds and on 04/08/24 the resident weighed 89.2 pounds. The resident experienced a 6.4 pound weight loss from 03/2024 to 04/2024 which constituted a severe 6.6% loss in one month and required and RN assessment.There was no documented evidence the RN had assessed the status of the resident, documented findings, and developed interventions as a result of the assessment. Resident 3 was observed independently eating lunch on 04/29/24 and breakfast on 04/30/24. The resident ate over 50% of the meals provided. On 05/01/24, survey requested a current weight for Resident 3 and weighed 91.8 pounds. This was an increase of 2.6 pounds from their 04/08/24 weight. On 05/01/24, 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 (Associate Executive Director), Staff 2 (Executive Director), and Staff 4 (RN/Health and Wellness Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by an RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in Chapter 851, division 047 for 1 of 1 sampled resident (#1) and two unsampled residents who received insulin injections by a facility unregulated assistive person (UAP). These residents were at risk for harm related to potential medical complications from the lack of an RN assessment of the resident's condition, UAP training, and supervision to ensure safety and accuracy of insulin administration. Findings include, but are not limited to:Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions, and outcomes pursuant OAR 851-045, including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client. During the acuity interview on 04/29/24, Resident 1 was identified as receiving both sliding scale and scheduled insulin by facility UAPs. In an interview with Staff 4 (RN/Health and Wellness Director) on 04/30/24, she reported that in addition to Resident 1, two other residents also received insulin. Resident 1's 04/01/24 through 04/29/24 MAR noted the resident received routine insulin every morning and at bedtime, plus sliding scale insulin before breakfast, lunch, and dinner. The MAR identified nine facility UAPs that administered insulin to the resident during the month of April.A progress note dated 04/30/24 by the RN noted a medication error had occurred on 04/29/24. The resident had an order for 50 units of Lantus scheduled at bedtime and a sliding scale insulin Novilin R before meals. The resident's blood sugar was 298 and reference to the sliding scale order the resident should have received 10 units of Novilin R. The RN documented, "The MT instead gave 10 units of Lantus and 50 units of Novilin R" instead of the ordered 50 units of Lantus and 10 units of Novilin R.In an interview on 05/01/24 Staff 14 (MT/Resident Care Assistant) and Staff 16 (MT), two of the UAPs who administered insulin, revealed they had not been delegated. Upon review of the delegation binder, there was no documented evidence that any of the residents receiving insulin injections had documentation that the resident's condition was stable and predictable or that the determination of frequency of the resident should be reassessed, including rationale. There was no documented evidence any of the facility UAPs had been delegated by an RN, including:* Rationale why the task could be safely delegated;* Skills, abilities, and willingness of the UAP to complete the task;* Task was taught to the UAP, and they were competent to safely perform task;* Written instructions available, including risks, side effects, response, and risk factors;* UAP were taught the task was client specific and not transferable;* Determination of frequency of the UAP should be supervised and reevaluated, including rationale; and* RN takes responsibility for delegating task and ensures supervision will occur for as long as RN was supervising performance. In an interview on 04/30/24 Staff 4 was unable to find documented evidence that delegation was completed according to OSBN Division 47 rules.On 05/01/24 at 9:19 am, 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 (Associate Executive Director), Staff 4 and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the above findings. On 05/01/24. the survey team requested an immediate plan to ensure insulin was administered by licensed or delegated staff in accordance with OSBN Division 47 Rules.On 05/01/24 at 1:00 pm, a plan to address the delegation issue which included licensed staff administering insulin until delegation was completed, was accepted and the situation was abated.

Based on interview and record review, it was determined the facility failed to have a system to coordinate care with outside providers to ensure continuity of care for 1 of 2 sampled residents (#1) who received outside services. Findings include, but are not limited to:Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes with diabetic polyneuropathy. A review of progress notes and "Outside Provider Communication Forms" from 01/23/24 through 02/08/24 identified the resident had been receiving HH wound care until 02/08/24, which included the following information made by the provider:* 01/23/24: "Check [left] great toe, clean [and] cover with band aide. Encourage resident to wear socks daily and HH [Skilled Nurse] to assess wound once a week;" * 01/26/24: "Please redress wound to left foot if it becomes dislodged. Apply betadine and bandage. Also, remove bandage and reapply if wet. [The] wound is macerated from being very wet;"* 01/29/24: "Keep wound dry and covered;"* 02/01/24: "Replace bandage if it is soiled/dislodged;" and* 02/08/24: "Recommending washing [resident's] feet at least every other day and applying Vaseline or lotion. If wounds on feet reopen, feel free to contact [HH] to come back in. Nurse moving to PRN [as needed]."There was no documented evidence the facility reviewed the outside provider information, updated the resident's service plan, informed staff of the new interventions, or implemented the treatment.In an interview on 05/02/24, Staff 4 (RN/Health and Wellness Director) reported she was unaware of the above information left by the outside provider. Staff 4 further indicated that the information and recommendations had not been added to the resident's service plan nor communicated to staff for implementation. The need to ensure the facility coordinated care with outside providers to ensure continuity of care was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Residents were put at risk related due to lack of delegation. The findings constituted an immediate plan of correction for the health and safety of the residents. Findings include, but are not limited to:Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following area:C282: OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching. On 05/01/24 at 9:00 am, the survey team requested an immediate plan of correction to address the issues identified. A plan was developed and at 1:00 pm was accepted by the team. The immediate jeopardy situation was abated. Refer to C282.

2. Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes and dementia with behavioral disturbance.The resident's MAR, dated 04/01/24 through 04/29/24, and physician's orders were reviewed. Resident 1 had a physician's order to report to the licensed nurse if CBG was less than 80 or more than 400. Between 04/01/24 and 04/29/24, Resident 1's CBG was less than 80 on eleven occasions. There was no documented evidence the facility notified the licensed nurse.The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.3. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance. The resident's MAR dated 04/01/24 through 04/29/24 and physician orders were reviewed, and identified the following medications did not have signed orders in the record: * Candesartan cilexetil 32 mg for high blood pressure;* Donepezil 10 mg for dementia;* Memantine 5 mg for dementia;* Sertraline 25 mg for depression;* Acetaminophen 500 mg for pain;* Olanzapine 2.5 mg for behaviors;* Guaifenesin 20 ml for cough;* Haloperidol 0.5 mg PRN for agitation; and* Hydrocodone 0.5 mg PRN for pain.During an interview on 04/03/24, Staff 4 (RN/Health and Wellness Director) acknowledged the resident did not have signed physician orders. Staff 4 stated the resident had recently switched providers and the new provider had been at the facility on 05/02/24; however, the provider failed to leave signed orders. Staff 4 was working with the provider to obtain current signed orders. The need to have signed physician orders for all medications administered by the facility was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's record for all medications the facility was responsible to administer, and medication and treatment orders were carried out as prescribed for 3 of 4 sampled residents (#s 1, 2, and 4) whose orders were reviewed. Findings include, but are not limited to:1. Resident 2 moved into the facility in 09/2016 with diagnoses including dementia.The resident's MAR dated 04/01/24 to 04/29/24 was reviewed, and identified the following:a. In an interview on 04/29/24, Staff 1 (Associate Executive Director) reported physician orders for Resident 2 were unable to be located, and that hospice would be faxing orders to the facility.A fax transmission dated 04/29/24 with physician orders signed 04/29/24 was provided on 04/30/24.b. Resident 2 had an order for morphine sulfate 20 mg/ml solution .5 ml (10 mg) by mouth every hour as needed for pain or shortness of breath. On 04/21/24 the MAR documented .25 ml was administered, which corresponded to the narcotics log.In an interview on 05/02/24, Staff 4 (RN/Health and Wellness Director), confirmed that she had administered less than the prescribed dose.The need to ensure written, signed physician orders were in the resident's facility record, and that physician's orders were followed, was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure staff attempted non-pharmacological interventions and documented they were ineffective prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#4) who was prescribed a PRN psychotropic medication. Findings include, but are not limited to:Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance.A review of Resident 4's MAR, dated 03/01/24 through 04/29/24, indicated the resident was prescribed haloperidol PRN, 0.5 mg every four hours for behaviors and agitation. Resident 4 was administered haloperidol on 03/18/24, 03/19/24, 03/31/24, and 04/10/24. There was no documented evidence non-pharmacological interventions were attempted with ineffective results prior to administration. In an interview on 05/02/24, Staff 14 (MT/Resident Care Associate) confirmed there was no documented evidence on the MAR that showed non-pharmacological interventions were attempted with ineffective results prior to administration. The need to document that non-pharmacological interventions were attempted without success prior to administering a PRN psychotropic medication was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:The facility posted staffing plan indicated the facility staffing levels were:* Day shift 2 MT's and 4 CG's;* Evening shift 1 MT and 3 CG's; and* Night shift 1 MT and 2 CG's.Review of the facility schedule for the month of April 2024 indicated the facility was staffing 2 MT's and 3 CG's for day shift.During interviews on 05/03/24, Staff 11 (Resident Care Associate), Staff 14 (MT), and Staff 17 (Resident Care Associate) indicated when the facility had 2 MT's and 3 CG's, the facility was understaffed and some of the scheduled showers were not always completed. Some resident showers got delayed to swing shift or the resident was first for showers on day shift the following day. On 05/03/24, the need to ensure the facility had adequate staff to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings.Refer to C361.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:The facility's ABST was reviewed on 05/01/24.There was no documented evidence all 22 required activities of daily living were addressed separately on the ABST being used by the facility.The need to use an ABST which addressed all the 22 activities of daily living for each resident and the amount of staff time needed to provide care in each area was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. This is a repeat citation. Findings include, but are not limited to:The facility's ABST was reviewed on 09/04/24.There was no documented evidence all 22 required activities of daily living were addressed separately on the ABST being used by the facility.On 09/04/24, the need to use an ABST which addressed all the 22 activities of daily living for each resident and the amount of staff time needed to provide care in each area was discussed with Staff 21 (Associate Executive Director), Staff 2 (Executive Director), and Staff 3 (District Director of Operations). They acknowledged the findings.

Based on record review and interview, it was determined the facility failed to ensure 2 of 2 sampled newly hired direct care staff (#s 13 and 14) completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 05/02/24 and 05/03/24. The following deficiencies were identified:Staff 13 (Resident Care Associate) and Staff 14 (MT/Resident Care Associate), hired 02/16/24 and 02/01/24 respectively, did not have documented evidence of having completed abdominal thrust training.The need to ensure staff completed all required training as specified in the OARs was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

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

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were in good repair. Findings include, but are not limited to:Observations of the facility on 04/29/24 and 05/03/24 identified the following areas in need of repair:*Coffee Bar and Dining room floors had gouges and scrapes; and*Coffee Bar and Dining room chairs were worn down to bare wood.On 04/30/24, an environment tour was conducted with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 5 (Maintenance Manager). They acknowledged the findings.

Concerns were identified in the following areas and the facility was provided with technical assistance:H 1518: Individual Door Locks: Key Access OAR 411-004-0020 (2)(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

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 C150, C156, C231, C360, 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. Findings include, but are not limited to:Refer to C 361.

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:a. Situations were identified where there was a failure of the facility to comply with the Departments rules that caused or were likely to cause an immediate threat to residents' health and safety. An immediate plan of correction was requested in the following area:C282: OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching.b. Refer to C252, C260, C262, C270, C280, C290, C300, C303, and C330.

Based on interview and record review, it was determined the facility failed to ensure activity evaluations addressed all required components and individualized activity plans were developed for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to:Residents 1, 2, 3 and 4's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect one or more of the following required components:* Residents' current preferences; * Abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations;* Adaptations necessary for the resident to participate; and* Identification of activities for behavioral interventions.There was no specific activity plan, reflecting the residents' activity preferences and needs, which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure residents had access to an enclosed, secured outdoor area. Findings include, but are not limited to:Observations of the facility interior on 04/29/24 revealed interior courtyard doors were locked, preventing residents from entering and exiting without staff assistance. There were no observations of inclement weather during that time.During an interview on 04/29/24 Staff 11 (Resident Care Associate) reported the interior courtyard doors were always locked.During an interview on 04/29/30 Staff 5 (Maintenance Manager) reported the interior courtyard doors have always been locked, and care associates are the ones who let residents in and out to the courtyard.On 04/30/24 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 (Associate Executive Director) and Staff 5 (Maintenance Manager) . They acknowledged the findings.

The findings of the kitchen inspection, conducted 3/12/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 03/12/24, conducted 05/13/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the second re-visit to the kitchen inspection of 03/12/24, conducted 07/25/24, 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.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.
The findings of the third revisit to the kitchen inspection of 03/12/24, conducted 09/19/24 and 09/20/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility ALF kitchen was completed on 03/12/24 from 11 am through 3:30 pm and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Floors and walls under dish machine;* Floors throughout kitchen;* Walk in cooler floors/corners/edges/walls;* Walls throughout kitchen;* Fans and metal cages of fans;* Reach in coolers and freezers;* Open shelving throughout kitchen;* Interior and exterior of microwave;* Interior and exterior of convection ovens;* Exterior and interior of steamer;* Range top, grill top;* Metal shelves storing pots/pans/dishes;* Knobs of steam table;* Steam table wells;* Cabinet with plate warmer;* Industrial can opener and housing;* Steamer with scale build up and dirty on interior and exterior;* Industrial mixer;* Door thresholds with food debris/splatter; * Interiors and exteriors of stainless steal drawers;* Go racks stored in walk in;* Metal racks in walk in cooler;* Freezer fan cages;* Outside and handles of trash cans;* Small appliances (blender/robot coupe);* Ice scoop holder; * Window seal and screens; and* Kitchen drains.b. The following areas were in need of repair: * Hole in wall under prep counter where cutting boards stored;* Three compartment sink faucet with leak;* Spring loaded sprayer broken and sitting at bottom of sink;* Caulking behind hand washing sink and ware washing area with black mold like substance;* Pipe from wall next to large fan with gap needing sealed; and* Sprinkler in walk in cooler leaking.c. Scoops/spoons observed in bulk food containers with handles touching food surfaces. Coffee filters stored uncovered and open to potential contamination.d. Multiple cutting boards and cutting surfaces were found heavily stained and scored. Multiple pans/utensils with damage and wear needing to be replaced. e. Multiple food items found in walk in cooler without proper labels and/or dates as required. Items found open or not sealed appropriately to protect from potential contamination. f. Multiple food packages were found open in dry storage.g. Shell eggs and liquid eggs stored over box of "fresh greens". Cardboard box of food items with visible wet debris. Staff stating sprinkler in walk in leaking.h. Multiple cooking/prep dishes were not stored inverted as required and were observed to have visible debris in them. i. Large meat roast observed being thawed under cold running water upon entry to kitchen. These roasts were then observed at 12:25 on a large pan on a go rack in the main kitchen. Again at 1:35 pm these meat roasts were still observed out of refrigeration on the pan on the go rack. j. Cardboard and recyclables were not stored appropriately and were not separate from food preparation areas. Staff 2 indicated they did not have a good space to store them until taking out to garbage area. k. At 12:05 a staff member entered into kitchen and got ice out of ice machine. The staff member did not wash hands and did not have their hair restrained as required.At 12:25 pm, the memory kitchen area was observed and noted the following areas in need of cleaning: Floors, plastic and metal shelves, toaster, utility carts, reach in fridges/freezers, walls, drains, hand washing sink, reach in oven. The ice machine lid was broken and did not close appropriately, falling to the floor when opened. The dish machine temperature gauge was not functioning properly and was not reaching the required 180 degrees F as required. Surveyor checking temperature with temp strips and the sanitation was validated, however no one was aware the gauges were not operating correctly. Facility staff were documenting temperature readings at 160-180 for final rinse temperatures. Staff 2 acknowledged the temperatures should be 180 and that staff had not alerted them to any temperatures under that requirement. Staff 2 (Dining Service Coordinator) toured kitchen areas with surveyor and acknowledged identified areas needing attention. At approximately 3:00 pm, surveyor reviewed above areas with Staff 1 (Administrator), who acknowledged the findings.
Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observation of the facility ALF kitchen was completed on 05/13/24 from 10:15 am through 12:45 pm and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Ceiling vent near prep area* Floors throughout kitchen;* Walls throughout kitchen;* Fans and metal cages of fan by serving area;* Open shelving throughout kitchen;* Interior and exterior of microwave;* Interior and exterior of convection ovens;* Exterior and interior of steamer;* Range top, grill top;* Metal shelves storing pots/pans/dishes;* Steam table wells;* Industrial can opener housing;* Steamer interior and exterior;* Industrial mixer;* Door thresholds with food debris/splatter; * Interiors and exteriors of stainless steel drawers;* Window sill and screens; and* Kitchen drains.b. The following areas were in need of repair: * Areas by electrical conduit/pipes with gaps. c. Scoops observed in bulk food containers with handles touching food surfaces.d. Multiple food items found in walk-in cooler without proper labels and/or dates as required. Container of cut tomatoes was found stored in walk-in cooler. It was dated 04/30/24 multiple days past seven days that is allowed per rule.e. Multiple food packages were found open in dry storage without open dates.f. Thawing meats were not stored correctly according to appropriate cook to temps to prevent potential cross contamination. Whole pork roasts were noted to be stored directly under ground meat products.At approximately 11:15 am, the memory kitchen area was observed and noted the following areas in need of cleaning: Floors, microwave, can opener and housing, toaster, utility carts, steam table wells, and reach in fridges/freezers. The ice machine lid was open exposing ice to potential contamination. Kitchen staff were interviewed and they were not able to correctly state the proper dish rise sanitation temperature. Staff stated rinse temperatures were ranging from 160-170 degrees F. Staff indicated appropriate sanitizing temperature was 170 degrees. Facility dishwashing temperature records documented 22 instances since 05/01/24 where the rinse temperature was under the required 180 degrees to effectively sanitize dishes. Staff 2 (Dining Service Coordinator) toured kitchen areas and Staff 3 (MC Administrator) toured memory care kitchenette with surveyors and acknowledged identified areas needing attention. At approximately 12:30 pm, surveyors reviewed above areas with Staff 1 (Interim Executive Director), who acknowledged the findings.
Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observation of the facility ALF kitchen was completed on 07/25/24 from 12:00 pm through 1:45 pm and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Floors throughout kitchen;* Fans and cages in walk in cooler;* Floors in walk in cooler;* Open shelving throughout kitchen;* Interior and exterior of convection ovens;* Exterior and interior of steamer;* Metal shelves storing pots/pans/dishes;* Baking "go" racks;* Number 10 can storage racks; and* Kitchen drains.b. Scoops were observed in bulk food containers with handles touching food surfaces.c. Box of frozen hamburger patties were found open and uncovered in the walk in cooler.On 07/25/24, Staff 2 (Dining Service Coordinator) toured the kitchen and acknowledged the findings. At approximately 1:30 pm, surveyor reviewed above areas with Staff 1 (Interim Executive Director) and Staff 3 (Memory Care Administrator), who acknowledged the findings.

Based on record review and interview, it was determined the facility failed to ensure 2 of 5 sampled staff (#s 2 and 3), who prepared food had active food handlers certificates. Findings include, but are not limited to: On 03/12/24 employee records were requested and reviewed to ensure staff had active food handlers cards on file. There were two employees, Staff 2 (Dining Services Coordinator) and Staff 3 (Cook) whose food cards could not be located. Staff 1 (Executive Director) acknowledged the need to have active food handler cards on hand for these individuals.

Based on interview and observation, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240.
Based on interview, observation, and record review, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C240.

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

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

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

The findings of the on-site investigation, conducted on 06/14/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered NurseNotes on Abbreviations: " The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. " Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate." Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. " If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on observation and interview,conducted during a site visit on 06/14/23, it was confirmed the facility failed to provide three daily nutritious, palatable meals. Findings include, but not limited to:In an interview on 06/14/23, Staff 2 (Caregiver) stated there were residents who complained about meals being late and often cold, however, the food was provided by the ALF and if the food was late it was because the ALF did not deliver the food on time, or the MCC dietary aide needed to rewarm the food prior to serving the meal. Meal service was from 12:00 pm-1:00 pm, and residents were usually served within 30 minutes.In an interview on 06/14/23, Staff 3 (Dietary Aide) stated s/he turned on the steam table 30 minutes before the meal, however, today s/he was unable to. S/He turned the steam table on when the food was placed inside the serving line. On 06/14/23 CS observed the following: ·11:41 am- food delivered to MCC kitchen. ·Five staff assisted with meal service with 18 residents in attendance. ·11:47 am-Staff 3 was taking temperatures of food provided, -BBQ beef tips: 168-degrees Fahrenheit -Cod: 133-degrees Fahrenheit -Vegetable mix. cauliflower, carrots, and broccoli: 169-degrees Fahrenheit -Brussels sprouts: 169-degrees Fahrenheit -Sweet potato fries: 155-degrees Fahrenheit -Baked beans: 161- degrees Fahrenheit·No steam was observed coming from the steam table or the food.·12:03 pm-Residents were offered small bowls of cantaloupe.·12:06 pm- First meals entered dining room and were served to residents. ·12:10 pm- A resident asked for salt and pepper for their meal, which staff provided within minutes of the request.·No residents were overheard complaining about the temperature of the food or the service time. ·12:18 pm- All residents had been served in the dining room. ·At the same time, a sample plate was provided to CS. The plate consisted of BBQ beef, cod, baked beans, steamed vegetables such as cauliflower, carrots, broccoli, brussels sprouts, and sweet potato fries. All food except the baked beans were cold when sampled. It was confirmed the facility failed to provide palatable meals.On 06/14/23, the findings were reviewed with and acknowledged by Staff 1 (Administrator).Verbal Plan of Correction: Staff 1, daily will have the dietary aide turn on the steam table before meal service by creating a log, in addition, s/he is looking into buying a warmer box to transfer food over from ALF to MCC. Will purchase the warmer box within the next month.

Based on observation and interview, conducted during a site visit on 06/14/23, it was confirmed the facility failed to ensure the glass and area surrounding the fireplace did not exceed 120-degrees Fahrenheit. Findings include, but are not limited to:On 06/14/23, CS took the temperature of the surrounding area of the fireplace. The temperature gage read 289-degrees Fahrenheit on one occurrence and 337-degrees Fahrenheit on the second. On 06/14/23, an interview with Staff 1 (Administrator) and Staff 4 (Maintenance Director) explained the facility has a TELS system to record the temperature of the fireplace weekly but that it has not been completed recently due to the facility not having a consistent maintenance director. CS observed Staff 4 take the temperature of the fireplace with his/her own temperature gage and the temperature was 223-degrees Fahrenheit. Both Staff 1 and Staff 4 acknowledged the temperature of the fireplace was higher than 120-degrees Fahrenheit.It was confirmed the facility failed to ensure the glass and area surrounding the fireplace must not exceed 120-degrees Fahrenheit.On 06/14/23, the findings were reviewed with and acknowledged by Staff 1 and Staff 4. Verbal plan of correction: Staff 4 called a vendor out before CS left the facility and stated they would be coming out on 05/22/23 to fix the temperature or the fireplace. Once the new maintenance personal is trained and working on their own, the ED and the maintenance person will do weekly checks for the temperature.

Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include: During an interview on 11/2/2022, Staff #1 (S1) stated, "I did not keep up with the required posting of the staffing plan when the acuity changed. "During an unannounced site visit on 11/2/2022, Compliance Specialist (CS) observed 3 Caregivers (CG) and 1 Med Tech (MT) working during the day shift.A review of the facility posted staffing plan and the facility ' s Acuity Based Staffing Tool (ABST) indicate that the facility staffing plan does not match the ABST. The above information was shared and acknowledged by S1 and S2 on 11/2/2022. Plan of Correction: S1 stated on11/14/2022 that the facility does staff to acuity, currently the posted staffing plan at the entrance has been updated to read 3 CG and 2 MT for day shift and going forward the designee will update this daily.

The findings of the kitchen inspection, conducted 08/11/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services: Meals, and Oregon Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit of the kitchen inspection, conducted on 11/22/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, OARs 411 Division 57 for Memory Care Communities, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.


The findings of the second revisit to the kitchen inspection of 11/22/22, conducted 2/3/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the third revisit to the kitchen inspection of 08/11/22, conducted 04/27/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, food was stored properly and surfaces were sanitized in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the MCC kitchen, food storage areas, food preparation, and food service on 08/11/22 revealed:* The following areas needed cleaning or repair: - The interior of the microwave oven had food debris; - A box fan had lint on the grate; - There was black mold on the wall above the warewashing dish area; - A piece of corner trim to the right of the warewashing area had come loose from the wall; and - Dust pans had accumulated dried debris.* Opened and leftover food items that were stored in the refrigerator were not consistently dated.* The kitchen lacked test strips for determining if the sanitizing solution used to wipe down surfaces was prepared properly.The findings were reviewed with Staff 2 (Dining Services Coordinator) on 08/11/22 at 1:30 pm. He stated his previous supervisor had not trained him on how to date food, and he had not been provided with chemical test strips.The findings were reviewed with Staff 1 (Executive Director) on 08/11/22 at 2:45 pm. He acknowledged the areas needing cleaning, and the need for additional training for kitchen staff.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, food was stored properly and surfaces were sanitized in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:Observations of the MCC kitchen on 11/22/22 revealed:The following areas needed cleaning or repair:*The interior of the microwave, refrigerators, freezers, and oven had food debris;*The top of the ware-washing machine had food and debris build-up on it;*There was black matter on the wall above and behind the ware-washing dish area; *A piece of two corner trim pieces to the right of the ware-washing area had come loose from the wall; and*Dust pans had numerous ants, debris, and food matter on it.Multiple opened and leftover food items that were stored in the refrigerators were not consistently labeled and/or dated.On 11/22/22, the findings of the MCC kitchen inspection were discussed with Staff 4 (Executive Director), Staff 5 (Assistant Executive Director), and Staff 6 (Cook). They Acknowledged the findings.
Facility will provide written training to all dining staff with the cleaning schedule, touching on all parts noted in re-survey. Dining Services Manager, Memory Care Administrator will audit the memory care kitchen, food storage, and dining areas and the signed cleaning log daily.Daily Dining Services Manager

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:Observations of the ALF main kitchen and food storage areas on 2/3/23 identified the following: * Splatters, spills, drips, dust and/or debris were observed on: - Floors behind, underneath and beside equipment and open shelving; - Vents and fire sprinklers; - Grill top, back splash and behind grill; - Stove top, exterior and interior of regular and convection ovens; - Ceiling and wall of walk in cooler; - Cooling fan covers in freezer; - Walls behind juice machine and by entrance/exit door to dining room; - Open shelving above steam table and where spices were stored; - The can opener blade and casing; - Interior and exterior of microwave and toaster and - Inside of plate warmer cabinet.* There were 2 holes observed under a prep area table. They were acknowledged by Staff 1 (Executive Director). There was significant ice build up on the door to the walk in freezer, in the walk in freezer as well and noted dripping and rusting areas in the walk in cooler. A large section of exposed pressed wood by a window seal was observed from the smooth cleanable surface pealing off. * Multiple items in walk in cooler found not labeled or dated.* Multiple items in walk in cooler found uncovered.* Multiple employees found not washing hands when entering kitchen area as well as not washing hands when changing from dirty tasks to clean tasks.* Kitchen staff observed to heat up a can of tomato soup and did not check the temperature before serving to resident.* Lunch item temperatures were not checked prior to start of service. They were removed from convection oven, placed in steam table, covers removed and staff served residents. Temperature logs were reviewed and multiple days of food temperatures were not recorded. Staff 1 (Executive director) and Staff 2 (Dining Services Coordinator) acknowledged temperatures were not recorded.* Cleaning task list and schedule was reviewed with Staff 2 and she validated multiple days were missing documentation. She did state that staff frequently forget to write it down.* Plan of correction presented by facility included weekly audits. Staff 1 was asked for documentation that audits were conducted and none was provided.The areas needing cleaning and the failure to follow safe food handling and preparation practices was reviewed on 2/3/23 with Staff 1 (Executive Director) and Staff 3 (Associate Executive Director). They acknowledged the findings.
Facility will implement Brookdale Menu Manager menus approved by Crandall Corporations Dieticians as well as real time trainings with kitchen staff. Will follow the Daily Diet Modification sheets. Will provide mid morning, mid afternoon, and evening snacks daily.Utilization of proper portioning serving tools to monitor correct servings of food servedMenus will be planned at least 2 weeks in advance and provide residents their copies of the menus.Any substitution will be recorded on the Menu Substitution LogDining Services Manager, Interim Director, Memory Care Administrator will monitor compliance by doing daily documented audits. Educating our Dining associates by inservices and actual real time trainings in Food safety and sanitation.ALF Main KitchenCleaning Schedule is in place.- Floors have been cleaned and is maintained by following cleaning schedules daily. Sweep and mop every after meal or as needed. - Maintenance have scheduled clean up and repairs of vents and fire sprinklers.- Scrubbed, clean and maintaining oven, grill and stovetop area by schedule, done daily by designated associate.- Finished cleaning cooler ceiling and walls. Scheduled cleaning is in place, or clean as needed.- Maintenance contacted repair company to fixed freezer/cooler.- Walls behind juice machine cleaned and being maintained daily.- Open shelving for spices is now organized and being maintained daily- Ordered new can opener to be installed- Microwave in brand new and daily clean up is part of assigned cleaning schedule- Scrubbed and cleaned plate warmer. Daily clean up is part of assigned cleaning schedule- 2 holes have been patched and will be painted - Replaced pressed wood with real wood and will be painted- Dining Leader continues to monitor practice of proper dating and food labeling - inserviced culinary associates.- Spot audits are being done by different department heads to ensure compliance in food safety and sanitation.- Proper heating of RTE food addressed. Instructed servers to request assistance from the cooks to properly take temperatures of any food before serving- Inservices going on for proper food holding temperatures of cold and hot foods. Taking and documenting internal temperatures of food to know if temperatures are correct before placing in steam table. Taking temperatures of food before start of meal service and every 30 mintes thereafter. Hot food should be kept hot, cold foods cold.- Temperature Logs are in place. Dining Leader monitors and inforce dailyContinually training and coaching associates to be compliance in Food Safety and Sanitation.

Based on observation and interview, it was determined the facility failed to comply with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility, except when the employee is alone in a closed room.Observations of staff during the kitchen inspection revealed multiple instances of staff failing to wear their mask properly by covering both their mouth and nose.On 11/22/22, the need to ensure all staff were properly wearing a face mask was discussed with Staff 4 (Executive Director), Staff 5 (Assistant Executive Director), and Staff 6 (Cook). They acknowledged the findings.

Based on interview and observation, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240.
Based on interview, observation and review of documentation, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C240

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.
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 240 and C 295.
Please refer to C295

Based on observation, record review 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

The findings of the re-licensure survey conducted 3/8/21 through 3/10/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a dayA situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause a resident serious harm. An immediate plan of correction to residents' health and safety was requested in the following area:OAR 411-054-0045 RN Delegation and Teaching;The facility put an immediate plan of correction in place during the survey and the situation was abated.
The findings of the first re-visit to the re-licensure survey of 3/10/21, conducted 7/6/21 through 7/7/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Division 57 for Memory Care Communities.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day


The findings of the second re-visit to the initial survey of 3/8/21, conducted 9/2/21, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the relicensure survey, conducted 3/8/21 through 3/10/21, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.Refer to deficiencies in the report.

Based on observation, interview and record review, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location to residents and visitors, and available for inspection. Findings include, but are not limited to:A tour of the facility conducted on 3/8/21 identified the following:* The survey book did not contain a copy of the most recent survey, including all revisits and plan of corrections; and* There was no posting of the name of administrator or designee in charge.The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (Executive Director) on 3/8/21. Findings were also discussed at the exit interview on 3/10/21.

Based on interview and record review, it was determined the facility failed to ensure complete and accurate records were maintained and records were not falsified for 2 of 6 sampled residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to:1. Review of Resident 2's records revealed a Temporary Service Plan (TSP) written by the former facility RN on 1/26/21. The TSP noted Resident 2 had a wound and "dressing change to [his/her] back everyday. Date and sign. This NOT being done. MT [Medication Tech] have been falsifying records. Neglect." During interviews on 3/8/21 and 3/9/21, Staff 1 (Executive Director), Staff 3 (LPN) and Staff 4 (RN), indicated they all reviewed TSPs, but they were not aware of the TSP dated 1/26/21. The need to ensure accurate records that were not falsified, was discussed with Staff 1 on 3/9/21. No further documentation was provided.
2. Resident 3 was admitted to the facility 2/2021 with diagnoses including Type II Diabetes. Facility admission paperwork also identified the resident as having "acute cognitive decline." Resident chart records, not limited to but including admission paperwork, service plans, evaluations and delegation, were reviewed during survey and found to be incomplete or inaccurate in the following areas: a) On 3/8/20 at 1:15 pm Staff 4 (RN) provided this surveyor a copy of two service plans for Resident 3. One dated 2/16/21 (the date the resident was admitted to the hospital from the assisted living facility), and one dated 3/8/21. Staff 4 indicated the 3/8/21 service plan was a "change of condition." The only changes noted on the 3/8/21 service plan were a few behavioral interventions. During an interview on 3/9/21 at 1:55 pm, Staff 1 (Executive Director) confirmed there was no initial service plan completed for the resident when s/he moved into the facility on 2/19/21. In the same interview Staff 4 stated she did not know why she had completed the 3/8/21 service plan for a "change of condition" but it could have been referring to when the resident went to the hospital from the ALF and then discharged into the memory care community. There was no reference to the residents hospital admission prior to moving to memory care or documentation regarding an emergency room visit on 3/2/21 for high blood sugar readings in the 3/8/21 service plan update. Staff 4 also confirmed she had not completed a recent assessment of Resident 3 prior to completing the 3/8/21 service plan, and was unsure why she completed the change of condition. b) The resident had experienced two falls since admit, on 2/28/21 and 3/1/21. On 3/9/21 at 1:55 pm the surveyor requested all fall investigations documentation. On 3/9/21 Staff 1 (Executive Director) provided incident reports for each fall which were dated 3/9/21. No prior fall investigations had been completed. c) On 3/9/21 surveyor requested copies of all physician orders related to changes in insulin administration and dosage since time of move in. On 3/10/21 at 10:13 am, Staff 4 provided a copy of an insulin order dated 3/5/21 indicating the resident was to receive an increase in Tuojco (insulin) of 70 units every morning. The resident's March 1st through 8th 2021 MAR indicated the resident was currently receiving 71 units of insulin daily. The surveyor again requested a copy of all signed orders since move in. At 11:26 am Staff 3 (LPN) provided copies of signed orders which had been faxed at 11:04 am from the pharmacy. Included in the orders was the same order received from Staff 4 at 10:13 am, however the zero for "70" units had been written over to state "71" units. It appeared the unit amount was changed without a signature.d) A review of Resident 3's delegation records on 3/8/21 indicated a "Diabetic Assessment" had been completed on 2/23/21. Further record review revealed the resident had been sent to the emergency department (ED) three times on 3/2/21 for blood sugar readings in excess of 600. On 3/9/21 the surveyor requested Staff 4 to re-assess the resident based on multiple dosage changes to insulin orders, the ED visit and consistently high blood sugar readings above 500. On 3/9/21 at 12:39 pm Staff 4 provided an updated assessment dated 3/4/21, but it was completed on 3/9/21. The assessment failed to mention the multiple changes in insulin dosage or the trip to the ED on 3/2/21. None of the assessments provided had Staff 4's name or signature indicating who had completed the assessments. The need to ensure resident records were complete, accurate and not falsified was reviewed with Staff 1 and Staff 4 multiple times throughout the survey. Deficiencies were also presented during the exit conference.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents, including unsafe transfer observations for 1 of 2 sampled residents (#5) and the failure to follow infection control guidelines to prevent the spread of COVID-19. Findings include, but are not limited to:1. Observations during the re-licensure survey, conducted 3/8/21-3/10/21, multiple Oregon Department of Human Services (ODHS) infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. The following issues were identified:* Failure to have a dedicated screener for all essential staff and visitors;* Failure to properly and consistently wear masks and eye protection;* Failure to ensure staff face shields were properly stored in individual containers/bags in the kitchen area;* Failure to provide disinfectant for staff use on face shields, prior to storage at the end of their shifts;* Failure to ensure furniture placement addressed the need for social distancing as well as residents being placed closely together during activities and meal time;* Failure to ensure hand sanitizer was readily available for staff and resident use, ensuring staff completed proper hand hygiene between clean and dirty tasks and that residents were assisted with hand hygiene throughout the day. During an interview with Staff 1 (Executive Director) on 3/8/21 and 3/9/21, the surveyor requested the facility implement the following recommendations:* Readjust furniture placement and spread residents out during meals and activities to encourage social distancing;* Designate a dedicated screener for all essential staff and visitors;* Re-educate staff on the proper use of face masks, eye protection and hand hygiene; and* Replace the missing disinfectant supplies from the PPE storage area.The need to ensure the facility consistently followed infection control practices, related to COVID-19 prevention, was discussed with Staff 1 on 3/8/21 and 3/9/21. She acknowledged the findings.2. Resident 5 was admitted to the facility in June 2017 with diagnoses including Alzheimer's disease and cerebral palsy.The resident's service plan dated 1/27/21 indicated the resident required two staff assistance for transfers. The service plan contained no information regarding the use of a gait belt. The resident required full assistance from staff for all her/his care and did not bear weight. The resident had a pommel cushion in place on the wheelchair. A pommel cushion has a raised circular or square extended section of cushion, 3-4 inches in height near the center front of the main cushion to prevent the user from sliding out of the wheelchair.Observations of the resident during transfers and ADL care on 3/9/21 showed the following:a. Resident 5 was in her/his wheelchair at the dining room table. The resident's wheelchair had a pommel cushion in place. The resident spilled a cup of juice into his/her lap which soaked the resident's pants. Staff 9 (CG) took the resident from the dining room to her/his bedroom to change her/his pants. Staff 9 and Staff 12 (CG) were both present in the resident's room. Staff 9 and 12 hooked their arms underneath the resident's armpits, grabbed hold of the waist band of the resident's sweat pants and lifted her/him up over the pommel part of the cushion and out of the wheelchair. The resident had her/his feet on the floor but was not bearing any weight and was slumping towards the floor as staff held onto the resident. The staff removed the resident's pants and brief then lifted the resident by the armpits, onto the pommel part of the cushion, then over the pommel and into the seat. The staff put the resident's brief and clean pants over her/his feet and again lifted the resident up into a partial standing position, in the same manner as the initial transfer. The resident did not bear weight and continued to slump lower towards the floor. The staff pulled up the resident's brief and then the resident's sweat pants and used the waist band to pull the resident up into the wheelchair. In interview on 3/9/21 Staff 9 indicated the staff provided full assistance with all the resident's care. The resident did not have a mechanical lift at this point, but some staff have asked because transfers could be very difficult. The resident could not hold herself/himself up at all. b. Resident 5 was taken to her/his room for incontinent care and to lay down. Staff 7 (CG) and Staff 8 (CG) were both in the room with the resident. A gait belt was put around the resident's waist, the staff looped their arms underneath the resident's armpits, grabbed hold of the gait belt and lifted the resident up and over the pommel part of the cushion and into a partial standing position. The resident's brief was removed, and a new brief was pulled up. The resident began to slump lower towards the floor on more than one point during the transfer. As the staff attempted to lift the resident up into the bed the resident lifted both legs up in the air. The staff were able to get the resident into the bed without lowering her/him to the floor. In interview on 3/9/21 Staff 7 and 8 indicated the resident could not bear any weight and would randomly throw her/his arms straight up in the air which was why the staff always used a gait belt. The staff indicated they obtained the gait belt from hospice because of transfer concerns. The staff further indicated sometimes it took three staff to provide care, two staff to hold the resident up/transfer and one to take care of the brief/clothes/perineal care. The staff stated they had made several requests for a lift for the resident but were told it was not needed.The need to ensure residents were assessed for and provided with, safe transfer techniques and appropriate equipment was discussed with Staff 1 (Executive Director), Staff 4 (RN) and Staff 5 (Business Office Coordinator) on 3/9/21. The staff acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that protected privacy and dignity in a homelike environment. Findings include, but are not limited to:Resident 5 was admitted to the facility in June 2017 with diagnoses including Alzheimer's disease and cerebral palsy.Observations of the resident on the morning of 3/9/21 showed the following:Resident 5 was in her/his wheelchair at the dining room table. The resident's wheelchair had a pommel cushion in place; a pommel cushion has a raised circular or square cushion 3-4 inches in height near the center front of the main cushion to prevent the user from sliding out of the wheelchair. The resident spilled a cup of juice into his/her lap which soaked the resident's pants. Staff 9 (CG) took the resident from the dining room to her/his bedroom to change pants. Staff 9 and Staff 12 (CG) were both present in the resident's room. The staff selected new pants for the resident and a brief. Staff 9 and 12 hooked their arms underneath the resident's armpits, grabbed hold of the waist band of the resident's sweat pants and lifter her/him up over the pommel part of the cushion and out of the wheelchair. The resident had her/his feet on the floor but was not bearing any kind of weight. Staff 9 commented to Staff 12 that she wanted to clean up the juice in the chair but no action was taken. The resident's wheelchair cushion had bits of food debris and was visibly wet with liquid. The staff removed the resident's pants and brief then lifted the resident onto the pommel part of the cushion, then over the pommel and into the seat. The resident was naked below the waist during the transfer and when placed into the wheelchair seat. The cushion was not cleaned or dried prior to putting the resident's exposed bottom into the seat. The staff put the resident's brief and clean pants over her/his feet and again lifted the resident up into a partial standing position, in the same manner as the initial transfer. The resident did not bear weight. The staff pulled up the resident's brief and then the resident's sweat pants and used the waist band to pull the resident up into the wheelchair. The resident's bottom was not previously cleaned from placement in the dirty seat, nor was the cushion cleaned prior to putting the resident back onto the seat once her/his pants were changed. In interview with Staff 9 on 3/9/21 she indicated the staff provided full assistance with all the resident's care. The resident's chair was not cleaned before putting her/him back in the chair because the wipes were not near by. The need to ensure residents were provided personal care in a dignified and respectful manner was discussed with Staff 1 (Executive Director), Staff 4 (RN) and Staff 5 (Business Office Coordinator) on 3/9/21. The staff acknowledged the findings.

2. Resident 2 was admitted to the facility in June 2019 with diagnoses including hydronephrosis of right kidney and Stage three chronic kidney disease.The resident had a nephrostomy (opening between the kidney and the skin) requiring tubing changes every six to eight weeks and required bandage changes until the area was healed. Review of Resident 2's records revealed a Temporary Service Plan (TSP) written by the former facility RN on 1/26/21. The TSP noted Resident 2 had a wound and "dressing change to [her/his] back everyday. Date and sign. This NOT being done. MT [Medication Tech] have been falsifying records. Neglect." During interviews on 3/8/21 and 3/9/21, Staff 1 (Executive Director), Staff 3 (LPN) and Staff 4 (RN), indicated they all reviewed TSPs, but they were not aware of the TSP dated 1/26/21. The need to investigate an allegation of neglect of care was discussed with Staff 1 on 3/9/21. No further documentation was provided.
3. Resident 1 was admitted to the facility in May 2016 with diagnoses including Alzheimer's disease. Review of incident investigations, progress notes and physician communications for 12/8/20 through 3/9/21 showed the following: * On 1/3/21 Resident 1 was holding another resident's arms behind their own back. The residents were separated and no injuries were noted. An investigation was completed and indicated abuse and neglect was ruled out. The incident was not reported to the local SPD office until 1/11/21. * On 2/7/21 Resident 1 was found in another resident's room shoving wet gloves in the other resident's face and Resident 1 stated s/he had struck the other resident. The victim was "sobbing and calling out NO, NO, NO." An investigation was completed but no report was made to the local SPD office until 2/12/21.* On 2/24/21 a progress note indicated Resident 1 attempted to move another resident around in a chair but had a hard time doing so and was upset. Resident 1 refused to let go and became more agitated and grabbed the other resident's hair in a firm hold. Resident 1's hand had to be physically removed from the other resident's hair. There was no documentation of a thorough and complete investigation of the incident to rule out abuse and neglect. No evidence could be located to show the incident was reported to the local SPD office. The need to ensure resident to resident altercations were investigated promptly and reported as appropriate was discussed with Staff 1 (Executive Director) on 3/10/21. She acknowledged the findings. Staff 1 was asked to report the 2/24/21 incident on 3/10/21. Confirmation of the report was received prior to survey exit.
Based on observation, interview and record review, it was determined the facility failed to report injures of unknown cause to the local SPD office as suspected abuse unless an immediate facility investigation reasonably concluded the injury was not the result of abuse, failed to immediately notify the local SPD office of any incident of abuse or suspected abuse and failed to promptly investigate incidents and take measures necessary to protect residents and prevent reoccurrence of abuse, for 3 of 5 sampled residents (#s 1, 2 and 4) with reportable incidents. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 2018 with diagnoses including Alzheimer's. A review of Resident 4's records and interviews with staff confirmed the resident was non-verbal. A review of progress notes indicated the following: * On 12/24/20 staff discovered a cut on the bottom of the resident's right foot "next to the pinkie toe." There was no documented evidence the injury of unknown cause had been immediately or thoroughly investigated to rule out potential abuse or had been reported to the local SPD office. * On 1/7/21 resident had an unwitnessed fall. Progress notes indicated resident was found on the floor on her/his right side and had a rug burn on her/his right shoulder. There was no documented evidence the fall with injury had been immediately or thoroughly investigated to rule out potential abuse or had been reported to the local SPD office. * On 1/13/21 resident was found on the floor next to her/his wheelchair outside her/his room in the hallway. Staff documented in the progress notes they had seen another resident walk down the hallway, and later confirmed by interviewing the second resident s/he had tried to push Resident 3 down the hallway but Resident 3 had fallen out of the wheelchair. There was no documented evidence the incident or fall had been immediately or thoroughly investigated to rule out potential abuse, or had been reported to the local SPD officeThe facility was directed to self-report these incidents to the local SPD office, confirmation the incidents were reported was received on 3/10/21.The need to ensure injuries of unknown cause or any incidents of abuse or suspected abuse were immediately investigated or reported as appropriate, was discussed with Staff 1 (Executive Director) on 3/10/21. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair and that staff followed infection control and handwashing practices, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:1. The facility kitchen was toured on 3/8/21 at 11:10 am. There were multiple areas soiled with debris, food splatter or grease build up and in need of cleaning or repair including:* Ceiling vent above mop storage closet was covered with black lint;* Walls, back splash and underside of the handwashing sink and 3 compartment sinks were visibly dirty;* Microwave interior was soiled with debris and was missing its tray;* Stove range, hood and sides were dirty and had greasy build up on the surfaces;* Shelves, underside and legs of prep counters in the kitchen and dishwashing areas were dirty and had grease build up on them; * Lids to the food storage containers in the pantry were cracked and had broken seals;* Main entry door to the kitchen and the doors to the office and mop storage closet were dirty, had chipped paint and molding was in need of repair or replacement;* Drains and pipes underneath handwashing sink and dishwashing machine had debris and were covered in black residue; and* Tile floor and grout throughout the kitchen and dishwashing area was in need of deep cleaning.2. There were multiple observations of employees engaged in poor infection control practices as follows: * On 3/8/21 at 11:16 am and 11:54 am, two different staff members were observed entering the kitchen and touching food service tools and equipment without washing their hands; and* On 3/8/21 at 11:45 am, a kitchen staff member was observed performing food service related tasks and then moving throughout the kitchen, touching multiple areas without doffing and donning a new pair of gloves; and The surveyor educated Staff 3 (Dining Services Coordinator) and other kitchen staff on proper handwashing procedures, food safety and infection control practices immediately following the observations. The surveyor conducted a kitchen walk-through with Staff 3 and Staff 1 (Executive Director) on 3/8/21 at 12:24 pm. They acknowledged the areas needed to be cleaned and repaired and Staff 1 reported that a plan would be put in place on 3/8/21 to address the findings.

Based on interview and record review, it was determined the facility failed to ensure a move-in evaluation addressed all required elements and to ensure quarterly evaluations were completed timely and reflective of the residents' current needs for 4 of 6 sampled residents (#s 2, 3, 4 and 6) whose evaluations were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in June 2019 with diagnoses including hydronephrosis of the right kidney and stage three chronic kidney disease.Resident 2's record revealed evaluations were completed on 10/15/20 and 3/8/21(first day of the survey). There was no documented evidence Resident 2's evaluation was updated quarterly as required. The failure to update the evaluation quarterly was shared with Staff 1 (Executive Director). No further information was provided.
2. Resident 6 was admitted to the facility on 2/22/21 with diagnoses including dementia.Resident 2's new move-in evaluation labeled "Resident Evaluation," dated 2/9/21 failed to address the following areas:* Behavioral problems;* Effective non-drug interventions;* Decision making abilities;* Transfers, toileting, bowel and bladder management and dental status;* Pain, drug and non-drug interventions;* Skin condition, list of treatments and indicators of nursing needs;* Ability to use call system;* Recent losses;* Unsuccessful prior placements;* History of dehydration or unexplained weight loss or gain; and * Ability to understand and be understood.The need to ensure move-in evaluations included all required elements was discussed on 3/9/21 with Staff 1 (Executive Director). She acknowledged the findings.
3. Resident 3 was admitted to the facility 2/19/21. Resident 3's new move in evaluation, dated 2/16/21 was reviewed on 3/8/21. The following required elements had not been answered or were missing from the initial evaluation:* Customary routines, including sleeping and bathing;* Spiritual and cultural traditions;* Physical health status including list of current diagnosis, medications and visits to healthcare practitioners;* Mental Health issues, including depression, thought disorders, history of treatment and effective non-drug interventions;* Decision making abilities;* How the resident copes with change or challenging situations;* Ability to understand and be understood;* Transportation; * Toileting; * Non-pharmaceutical interventions for pain; and* Recent losses. The need to ensure new move in evaluations address all required elements was discussed with Staff 1 (Executive Director) on 3/9/21. She acknowledged the findings. 4. Resident 4's quarterly evaluation, dated 3/5/21, was reviewed on 3/10/21 during survey. The evaluation was inaccurate or not reflective of the resident's current care needs or health status in the following areas: * Current list of medications;* Behaviors and interventions;* Pain, including areas of pain, non-verbal expression of pain and non-pharmaceutical interventions; * Full assist with ADL care; * Falls, including recent falls and interventions; and * Weight monitoring.The need to ensure quarterly evaluations accurately reflected residents current health status and care needs was discussed with Staff 1 (Executive Director) on 3/10/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status, provided clear direction to staff, were available for staff and were being followed for 3 of 6 sampled residents (#s 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in June 2017 with diagnoses including Alzheimer's disease. Resident 5's service plan was not reflective of the resident's current status, lacked clear direction to staff and/or was not being followed by staff:* Floating heels;* Gait belt use;* Appropriate transfer status;* Repositioning;* Foam pool noodle placement under the mattress;* Supervision of the resident when up in her/his wheelchair; and* Incontinence care and brief changes.The need to ensure all resident service plans were reflective, followed and provided directions to staff was discussed on 3/9/21 with Staff 1 (Executive Director) and Staff 4 (RN). The staff acknowledged the findings.
2. Resident 3 was admitted to the facility 2/19/2021 with diagnoses including cognitive decline and type II diabetes.During an acuity interview on 3/8/21, Resident 3 was identified as a new move-in to the facility. Upon request for documents of sampled residents, Staff 1 (Executive Director) stated the resident's most current service plans were located in binders for staff reference.On 3/8/21 and again in a second interview on 3/9/21, Staff 1 confirmed the only information available to staff for Resident 3 was a temporary service plan, dated 2/19/2021, which was located in the service plan binder. The temporary service plan identified the resident as a new move-in with "aggression" and stated the following: "more info to come about resident;""Resident expressed anger related to fears about where wife is and if [spouse] is dead;""Reassure Resident [spouse] is in the hospital ...:" and"If [s/he] becomes violent, call 911, then advise nurse."There was no documented evidence an initial service plan had been developed prior to move-in based on the initial evaluation of resident, identified the needs and preferences of Resident 3, was readily available to staff, or provided clear direction regarding the delivery of services. The need to ensure initial service plans were completed for all residents prior to move in was reviewed with Staff 1 on 3/9/21. She acknowledged the findings. 3. Resident 4 moved into the facility March 2018 with diagnoses including Alzheimer's disease. Resident 4's 12/15/2021 service plan and temporary service plans were reviewed during survey. The service plans and temporary service plans failed to reflect the residents current status or care needs in the following areas:* Behaviors and interventions;* Resistance to care;* Falls and current interventions;* Pain and non-pharmaceutical interventions;* Potential for weight loss; and * Full assist with ADL care. The need to ensure resident service plans were accurate, updated and provided clear direction to staff on the delivery of services was reviewed with Staff 1 (Executive Director) on 3/10/21. She acknowledged the findings.

2. Resident 10 was admitted to the facility in 6/2017 with diagnoses including dementia.A review of Resident 10's 6/14/21 service plan revealed the service plan was not reflective, did not provide clear instruction to staff and/or was not being followed in the following areas:* Gait belt use for transfers; and* Contractures to both arms and hands.The need to ensure the service plan accurately reflected the current needs of the resident, provided clear instructions and was followed by staff was discussed with Staff 1 (Executive Director/LPN), Staff 20 (RN) and Staff 23 (RN Consultant) on 7/7/21. They acknowledged the findings.
3. Review of Resident 9's 6/25/21 service plan revealed it was not reflective of the resident's current status and did not provide clear direction to staff in the following areas: * Transfers;* Skin;* Health shakes; and * Cognition/communication. The need to ensure service plans were reflective of the resident's current status and provided clear direction to staff was discussed with Staff 1 (Executive Director/LPN), Staff 20 (RN) and Staff 23 (RN Consultant) on 7/7/21. 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 needs and status, provided adequate instruction to staff regarding the provision of care and/or was followed for 3 of 4 sampled residents (#s 8, 9 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 6/2021 with diagnoses including dementia.A review of Resident 8's 6/6/21 service plan revealed the service plan was not accurate and/or was not being followed in the following areas:* Food being cut up for the resident; and* Level of assistance required for ADLs.The need to ensure the service plan accurately reflected the current needs of the resident and was followed by staff was discussed with Staff 1 (Executive Director/LPN), Staff 20 (RN) and Staff 23 (RN Consultant) on 7/7/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and the condition was monitored for 4 of 5 sampled residents (#s 1, 2, 4 and 5) who experienced changes of condition. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in June 2019 with diagnoses including hydronephrosis of the right kidney and stage three chronic kidney disease.Residents 2's clinical record reviewed from 2/9/21 - 3/5/21, revealed the following: * On 2/9/21, Resident 2 went to the local hospital with a blocked nephrostomy tube (opening between the kidney and the skin). The tube was replaced, an antibiotic was prescribed, and nephrostomy tube dressing change instructions were provided; and* On 2/15/21, Resident 2's tube came out and s/he went to the local hospital for tube replacement. The resident returned to the facility with a nephrostomy tube dressing change instructions.There was no documented instructions for staff on what to monitor regarding the resident's wound and antibiotic use or whom to report to if needed. During the survey, the resident's nephrostomy bandage was observed to be intact. In an interview on 3/9/21, Staff 12 (CG) stated she was unaware of what to do if the resident's bandage was removed or who to report to if needed.The need for the facility to ensure instructions to staff for monitoring Resident 2's wound and documenting the progress of short term conditions, was discussed with Staff 1 (Executive Director) on 3/10/21. No further information was provided.
2. Resident 1 was admitted to the facility in May 2016 with diagnoses including dementia. The resident's 3/4/21 service plan, 12/1/20 through 3/9/21 progress notes, temporary service plans and physician faxes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident specific directions to staff in the following areas:* Skin status;* Hallucinations, agitation and aggression;* Resident to resident altercations;* Falls; and* Weight changes.The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly, provided clear resident specific directions to staff and interventions were reviewed for effectiveness was discussed on 3/9/21 and 3/10/21 with Staff 1 (Executive Director) and Staff 4 (RN). The staff acknowledged the findings. 3. Resident 5 was admitted to the facility in June 2017 with diagnoses including Alzheimer's disease.The resident's 1/27/21 service plan, 12/1/20 through 3/9/21 progress notes, hospice notes, temporary service plans and physician faxes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident specific directions to staff in the following areas:* Brown tinged discharge from the genitals;* Weight changes; and* Seizure.The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly, provided clear resident specific directions to staff and interventions were reviewed for effectiveness was discussed on 3/9/21 and 3/10/21 with Staff 1 (Executive Director) and Staff 4 (RN). The staff acknowledged the findings.
4. Resident 4 was admitted to the facility in March 2018 with diagnoses including Alzheimer's disease. A review of resident's progress notes, service plan, incident reports and temporary service plans (TSP) indicated the resident had experienced unwitnessed falls on the following dates: * 1/7/21 resident was found on the floor in his/her room on his/her right side. A "rugburn" was noted on the resident's hairline at the base of the skull;* 1/11/21 resident was found on the floor next to his/her bed with a "blanket and pillow". A TSP written the same day instructed staff to check on resident every "30 minutes when resident is in bed or wheelchair";* 1/13/21 resident was found on the floor next to his/her wheelchair in the hallway in front of resident's room. The facility investigation indicated another resident from a different hall had attempted to push the resident in his/her wheelchair and Resident 4 fell out of the wheelchair. A TSP written the same day instructed staff to lock Residents 4's door; and* 1/14/21 Resident was found on the floor "in the fetal position" with a blanket and pillow. Staff documented resident had a rug burn on the right shoulder. A TSP written the same day instructed staff to conduct hourly checks, "don't put in bed unless [resident] is ready, and to "keep door open to prevent anxiety and falls." There was no documented evidence the facility had monitored previous fall interventions for effectiveness, had thoroughly investigated to ensure staff were following previous fall interventions subsequent to each new fall, or that the facility had determined the cause of the falls. The need to ensure resident fall interventions and monitoring for the effectiveness of previous interventions for each subsequent fall a resident might have was discussed with Staff 1 (Executive Director) on 3/10/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 2 sampled residents (#1) who experienced significant changes of condition related to weight loss. Findings include, but are not limited to:Resident 1 was admitted to the facility in May 2016 with diagnoses including dementia. Weight records, dated 12/10/20 through 1/8/21 and progress notes dated 12/8/20 through 3/8/21, indicated the resident experienced a 15.3 pound weight loss. This constituted a 8.58% severe weight loss in one month. The facility failed to ensure an RN assessment was completed for the weight loss which documented findings, resident status and interventions made as a result of the assessment.Progress notes and physician communications dated 12/8/20 through 3/9/21 indicated the resident had contracted COVID-19 and was gone to a specialized facility from 12/19/20 through 1/3/21. The resident was weighed daily prior to her/his illness and upon her/his return, to monitor potential gains related to congestive heart failure. The resident's weight at the time of survey was stable with no further losses noted. The resident was admitted to hospice on 3/4/21 due to a continued decline in abilities.Multiple observations of the resident between 3/8/21 and 3/10/21 showed the resident was independent with her/his meal once it was delivered. The resident ate in the dining room, received cut up foods and 1-2 cups of fluid. The resident ate 75-100% of the meals observed and also accepted snacks/drinks when offered during activities or hydration pass. In interviews on 3/9/21 and 3/10/21, Staff 1 (Executive Director) confirmed there was no additional information regarding an RN assessment from the previous nurse. Staff 4 (RN) had been helping in the facility for approximately three weeks. Staff 1 indicated the resident's intake had improved once s/he returned to the facility and was recovered from the COVID-19 infection. The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 and Staff 4. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the administration of insulin injections by unlicensed staff was done in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules Division 47, RN Delegation, for 1 of 1 sampled resident (# 3) who received insulin injections from unlicensed staff. Unlicensed staff working in the memory care had not been delegated to administer insulin. Findings include but are not limited to: Resident 3 was admitted to the MCC in February 2021 with multiple diagnoses including Type II Diabetes. During an acuity interview on 3/8/21, Resident 3 was identified as having insulin-dependent diabetes and was being given insulin injections by non-licensed staff. Delegation records, resident chart records and MARs (dated 2/19/21 through 3/8/21) for Resident 3 were reviewed on 3/8/21 and revealed the following:Resident 3 had been admitted to the hospital from the communities Assisted Living Facility (ALF) on 2/16/21 and transferred to the MCC upon discharge, 2/19/21 for "mismanaged insulin" and "acute cognitive decline."* Resident 3 required daily CBG checks and insulin injections.* On 2/23/21 Staff 4 (RN) completed a "Diabetic Assessment" for Resident 3, five days after the resident moved into the memory care facility. * March and February MARs (2/19/21 through 3/7/21) indicated Staff 9 (MT), Staff 10 (MT), Staff 13 (MT) and Staff 16 (MT) had initialed the MARs indicating they had administered insulin on multiple occasions to Resident 3. On 3/5/21 Staff 4 completed delegation to a non-licensed staff, Staff 13 (MT), no other non-licensed MCC staff had been delegated to administer insulin as of 3/8/21; and* Between 2/19/21 and 3/8/21 Resident 3 had multiple changes to insulin orders and had been sent to the emergency department three times on 3/2/21 for blood sugar readings above 600. On 3/9/21 Staff 4 confirmed she had not reassessed the resident when s/he returned to the community to determine whether or not the resident was stable and predictable enough for delegating unlicensed staff for insulin administration.During an interview on 3/8/21 at 4:05 pm, Staff 4 confirmed Staff 13 had been delegated on 3/5/21, no other staff in the MCC had been delegated prior to or subsequent to 3/5/21. Staff from the ALF had been administering insulin injections to Resident 3 but since staff from the ALF were not "activated in the system" the MCC MTs were signing the MAR for insulin administration. Staff 4 further stated she was unsure which staff from the ALF had been administering the insulin, "it could have been several staff." At approximately 4:15 pm on 3/8/21 the facility was directed to develop and submit an immediate plan of correction to the survey team. A plan of correction was received and approved by the survey team on 3/8/21 at 5:21 pm for the delegation and the resident's insulin administration. The need to complete a thorough RN assessment of the resident and delegations as required by OSBN rule, in order to ensure the safe administration of insulin injections, was discussed with Staff 1 (Executive Director) and Staff 4 throughout the course of the survey. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:C 282: DelegationC 301: Systems: Medication AdministrationC 302: Systems: Tracking Controlled SubstancesC 303: Systems: Medication and Treatment Orders C 330: Systems: Psychotropic MedicationsThe unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 (Executive Director) and Staff 4 (RN) on 3/8/21, 3/9/21 and 3/10/21. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure medications administered by the facility were documented by the same person who administered the medication for 2 of 5 sampled residents (#s 3 and 4) who were administered insulin injections and supplemental shakes. Findings include, but are not limited to:1. Resident 3 was admitted to the MCC February 2021 with diagnoses including Type II Diabetes, which required daily CBG's and insulin injections. Resident 3's delegation records and 2/19/21 through 3/7/21 MARs were reviewed during the survey. Record review indicated Staff 13 (MT) had been delegated on 3/5/21 but had been signing on the MAR as having administered the resident's insulin seven times between 2/19/21 and 3/5/21. The records also indicated Staff 9 (MT), Staff 10 (MT), and Staff 16 (MT) had signed the residents MAR on multiple occasions indicating they had administered the resident's insulin.During an interview on 3/8/21, Staff 4 (RN) confirmed staff from the assisted living facility had been administering insulin injections since the time of the resident's move in, but documenting the administration under the MCC staffs names on the MAR.The need to ensure medications administered by the facility were documented by the same person who administered the medication was discussed with Staff 4 on 3/8/21. She acknowledged the findings. 2. Resident 4's 2/1/21 through 3/8/21 MARs were reviewed during survey and indicated the resident was receiving supplemental shakes three times a day "with snack cart." During an interview on 3/10/21 Staff 10 (MT), confirmed caregivers were responsible for providing the resident with health shakes during the day "during meals," but Med Techs had been signing as having administered the health shakes to the resident. The need to ensure medications administered by the facility were documented by the same person who administered the medication was discussed with Staff 1 (Executive Director) on 3/10/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 4 sampled residents (#4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:Resident 4 was admitted to the facility in March 2018 with diagnoses including Alzheimer's disease and age related osteoporosis. Physicians orders dated 9/24/20, 2/1/21 through 3/10/21 MARs, controlled substance disposition logs and the medication were reviewed and showed the following: Resident 4 had physician's orders for Tramadol 50 mg 1 tablet twice daily for pain. * The 2/11/21 8:00 am dose of Tramadol 50 mg was recorded on the MAR and the disposition log as administered with the remaining doses recorded as 18.* The 2/11/21 8:00 pm dose of Tramadol 50 was recorded on the MAR and the disposition log as administered however, the recorded number of doses remaining was not changed to reflect the dose as given. The remaining doses were again recorded as 18.Comparison of the medication dosing card, the disposition log and the MARs showed the amount of medication left was reflected accurately on the log. The MAR and progress notes did not include information regarding exceptions for a missed dose of Tramadol on 2/11/21.During an interview on 3/10/21, Staff 2 (LPN) verified she had initialed the medication dosing card to signify that the count was correct on this date. Staff 2 stated she would have only initialed the card if the count on the card matched the remaining doses, however it was possible the employee who recorded the 2/11/21 8 pm dose of Tramadol 50 mg, did not administer the dose to Resident 4, and the employee failed to make a note on the MAR reflecting the missed dose. Staff 2 stated she would provide education to the employee. The requirement to have a system in place for accurately tracking controlled substances administered by the facility was discussed with Staff 1 (Executive Director) and Staff 2 on 3/10/21. They acknowledged the findings.

2. Resident 3's chart records, including physician orders and 2/19/21 through 3/8/21 MARs were reviewed during survey. The records failed to include all signed physician orders related to the amount of insulin to be administered daily. The need to ensure written, signed physician orders were documented in the resident's facility record for all medications the facility was responsible to administer was reviewed with Staff 1 (Executive Director) and Staff 4 (RN) during survey. They acknowledged the findings. 3. Resident 4's physician orders and 2/1/21 through 3/8/21 MARs were reviewed during survey. Resident 4 had been prescribed two PRN psychotropic medications for anxiety. Olanzapine 2.5 mg and Lorazepam 0.5 mg. The order for Olanzapine included instructions to administer first and "If Olanzapine ineffective in 1 hour, use lorazepam."Resident 4's 2/1/21 through 2/28/21 MAR indicated Lorazepam had been administered on 2/11/21, 2/23/21 and 2/24/21 first, with no documented evidence the Olanzapine had been administered prior with ineffective results. The need to ensure medication orders were carried out as prescribed was reviewed with Staff 1 (Executive Director) on 3/10/21. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure physicians orders were available in the residents' records and were carried out as prescribed for 3 of 5 sampled residents (#s 1, 3 and 4) whose orders were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in May 2016 with diagnoses including dementia. The resident's 9/23/20 signed physician orders, 3/4/21 and 3/5/21 hospice orders, controlled substance disposition logs and the 2/1/21 through 3/10/21 MARs showed the following:a. Observation of the controlled substance storage showed a full medication card of Lorazepam with Resident 1's name. The medication was not reflected on the MARs and there was no physicians order for the use of the medication in the resident's record. The medication had not been administered to the resident.b. An order for daily weights was noted and included parameters to report to the physician if the resident showed a gain of 3 lbs or more in one day or 5 lbs in a week.* A gain of 3.4 lbs was noted between 2/20/21 and 2/21/21. There was no documentation the physician was notified of the gain as ordered.* No daily weights were recorded on 14 occasions between 2/1/21 and 3/2/21.The need to ensure orders were available in the resident's record for all prescribed medications and were administered as ordered by the prescriber was discussed with Staff 1 (Executive Director) on 3/10/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 3 sampled residents (#4) who were prescribed PRN medications to treat the residents' behaviors. Findings include, but are not limited to:Resident 4 was prescribed PRN Olanzapine and Lorazepam to treat symptoms of anxiety. The 2/2021 and 3/1 through 3/8/21 MARs indicated the resident was administered one or both medications on 34 occasions.The facility failed to document non-pharmacological interventions were attempted and ineffective prior to administering the psychotropic medication on 33 of the 34 occasions. The need to ensure staff attempted and documented non-pharmacological interventions were ineffective prior to administering PRN psychotropic medications to treat a resident's behavior was discussed with Staff 1 (Executive Director) on 3/10/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:1. Fire drill and life safety training records from 9/4/2020 to 3/6/21 were reviewed. The following was not documented in the training records: * The escape route used;* Problems encountered and comments related to residents who resisted or failed to participate in the drills;* Evacuation time period needed; and * Number of occupants evacuated.2. There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months. The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Executive Director) and Staff 6 (Maintenance Supervisor) on 3/9/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code. Findings include, but are not limited to:Fire drill and life safety training records from 9/4/2020 to 3/6/21 were reviewed with Staff 6 (Maintenance Supervisor) on 3/9/21 and revealed the facility failed to identify what alternate escape routes were used during the drills.During interviews on 3/9/21, Staff 7 (CG) and Staff (20) indicated they were unaware of where the point of safety was to evacuate residents.The failure of the facility to conduct fire drills in accordance with the Oregon Fire Code was discussed with Staff 1 (Executive Director) and Staff 6 on 3/9/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:Refer to C260.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the facility's common use areas were maintained and in good repair, and failed to ensure facility grounds were kept orderly and free of litter and refuse. Findings include but are not limited to:The interior and exterior of the building was toured on 3/8/21 at 10:14 am. The following issues were noted:* The North courtyard and building front entrance walkway areas had drop offs of up to two inches measured from the concrete to the planting surface bed. This created a potential tripping and/or fall hazard for residents;* Large exterior dumpster's containing bags of garbage and furniture were uncovered; and* The North courtyard was observed to have multiple garden tools unsecured and had stacks of unused potting containers near the doorway.The need to ensure the facility grounds were kept orderly and free of refuse, refuse containers were covered and exterior pathways did not have potential tripping hazards related to drop offs was discussed with Staff 1 (Executive Director) and Staff 6 (Maintenance Supervisor) on 3/8/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. Findings include, but are not limited to:A tour of the laundry room on 3/8/21 revealed the following:The washing machines did not include a hot rinse option; and the facility was using an unlabeled laundry powder for two machines and liquid household detergent for the newer machine without a chemical disinfectant. Interview with Staff 8 (CG) on 3/8/21 at 11:30 am indicated the caregivers completed laundry tasks for residents and used the unmarked powder detergent for the two older machines and a household liquid detergent in the new machine. She indicated she was unaware of a hot rinse setting and stated that no chemical disinfectant was used.A facility tour was done with Staff 1 (Executive Director) and Staff 6 (Maintenance Supervisor) on 3/8/21. Staff 6 said he "thought the water temps were the same as the rest of the building, between 110-120 degrees" and that he did not have an information manual for the washing machines.The failure to ensure soiled laundry was properly laundered and the need for a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used was discussed with Staff 1 (Executive Director) and Staff 6 (Maintenance Supervisor) on 3/8/21.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in the locations that were subject to incidental contact by individuals. Findings include, but are not limited to:During a tour of the facility on 3/8/21, the following observations were made:The front grate of a simulated fireplace located in the common area of the building entrance reached a surface temperature of 142 degrees Fahrenheit. Staff 1 (Executive Director) and Staff 6 (Maintenance Supervisor) were informed of the excess temperatures and acknowledged the need to ensure the fireplace grate and screens did not exceed 120 degrees Fahrenheit. They acknowledged the findings.On 3/9/21, a random check of the fireplace revealed it was off without any heat and a sign covered the switch.

Based on observation and interview, it was determined the facility failed to ensure all doors that exited to the interior courtyards were equipped with operational alarming devices or other acceptable systems to alert staff when residents exited into the courtyard. Findings include, but are not limited to:A tour of the facility on 3/8/21, revealed there were no exit door alarms that alerted staff when the doors were opened to the North and South courtyards.During a walk through of the environment on 3/8/21 at 2:15 PM, Staff 1 (Executive Director) and Staff 6 (Maintenance Supervisor) verified alarms were "turned off" and acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:The licensee is responsible for the operation of the MCC and the provision of person-directed care that promotes each resident's dignity, independence and comfort. This includes the supervision and overall conduct of the staff.During the relicensure survey, conducted 3/8/21 through 3/10/21, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number and severity of citations. Refer to deficiencies in the report.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 160, C 200, C 231, C 240, C 420, C 422, C 510, C 530, C 540 and C 555.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 16, 17 and 19) completed pre-service training with all required elements and demonstrated competency in all required memory care specific training topics within 30 days of hire. Findings include, but are not limited to:Review of the facility's training records on 3/09/21 revealed there was no documented evidence Staff 16 (MT), hired 12/18/20, Staff 17 (CG) hired 11/5/20 and Staff 19 (CG) hired on 12/12/20 completed all required elements of the pre-service training prior to beginning job duties including:* Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and* Environmental factors that are important to a resident's well-being.The facility lacked documented evidence Staff 16, 17 and 19 demonstrated competency within 30 days of hire related to the following required training topics: * Role of service plans in providing individualized care;* Identification, documentation and reporting changes of condition;* Conditions that require assessment, treatment, observation and reporting; and* General food safety, serving and sanitation. The need to ensure newly hired staff completed pre-service training with all required elements and demonstrated competency in all required memory care specific training topics within 30 days of hire was discussed with Staff 1 (ED) and Staff 5 (Business Office Coordinator) on 3/9/21. The acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure that 1 of 6 sampled residents, (#2), had a diagnosis of dementia and was in need of support for the progressive symptoms of dementia for safety, physical or cognitive function prior to being admitted to the memory care community. Findings include, but are not limited to:Resident 2 was admitted to the facility on 6/21/19. On 3/8/21 review of clinical records for Resident 2 revealed no diagnosis of dementia. During an interview on 3/8/21 with Staff 11 (Regional RN), initial move-in paperwork dated 6/4/19 was reviewed for Resident 2 and revealed no diagnosis for dementia or the need of a secured environment. The need to ensure that residents residing in the memory care community have a clear diagnosis of dementia which is progressive and requires a secured environment for residents' safety, physical or cognitive function was reviewed with Staff 1 (Executive Director) on 3/9/21. Later that day, Staff 1 provided the surveyor with a physician's order which contained a dementia diagnosis for Resident 2.

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, C 300, C 301, C 302, C 303 and C 330.

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.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose activity plans were reviewed. Findings include, but are not limited to:Residents 1 ,2, 3, 4 and 5's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect one or more of the following required components:*Residents' current preferences; *Abilities and skills; *Emotional/social needs and patterns; *Physical abilities and limitations;*Adaptations necessary for the resident to participate; and*Identification of activities for behavioral interventions.There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.On 3/10/2021 the need to evaluate and develop individualized activity plans including all required components for each memory care resident was discussed with Staff 1 (Executive Director) who acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 5 sampled residents (#1) with documented behaviors. Findings include, but are not limited to:Resident 1 was admitted to the facility in May 2016 with diagnoses including dementia.Resident 1's record documented behaviors including anxiety, exit seeking, yelling, hitting staff and aggression towards other residents including hitting and grabbing.The resident's service plan, dated 3/4/21, did not address the behaviors and/or lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 3/10/21 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Executive Director) and Staff 4 (RN). The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide access to the secured outdoor space without staff assistance. Findings include but are not limited to:On 3/8/21 at 8:45 AM, the doors to the secured North courtyard were observed to be locked. A keypad code was required to access the outside area.Interview with Staff 15 (Activities Assistant) on 3/8/21 at 8:45 am indicated the South courtyard was unlocked from 9:00 am to 5:00 pm and that North courtyard was "locked for the season."Interviews with Staff 1 (Executive Director) and Staff 6 (Maintenance Supervisor) indicated doors to the North courtyard were unlocked during the day but the South courtyard was locked seasonally. In a tour of the South courtyard, Staff 6 used a keypad to unlock the courtyard door. When asked why the courtyard was locked, Staff 1 responded "it's not." Review of the "Brookdale courtyard - secured patio access policy", dated 3/2020, stated "Courtyard and secured patio access doors should be unlocked and alarms deactivated from dawn to dusk to allow for residents' access."Follow up observations on 3/8/21 at 2:12 pm, 3/9/21 at 10:30 am and 3/10/21 at 10:15 am, revealed locked doors to both North and South courtyards.The need to provide access to the secured outdoor space without staff assistance was discussed with Staff 1 on 3/10/21. She acknowledged the findings and reported Staff 6 had added alarms to the courtyard doors and they would be unlocked during the day.Follow up observation on 3/10/21 at 2:31 pm, revealed South courtyard doors were still locked, and required staff use of keypad to be accessed.