Waterford Grand Memory Care

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

Based on observation, interview, and record review, it was determined the facility failed to ensure injuries of unknown cause were promptly investigated to rule out abuse and reported to the local SPD office as required for 1 of 1 sampled resident (#4) whose incidents were reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 06/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 11/01/24 service plan, 10/22/24 through 01/17/25 progress notes, physician communications, and incident investigations were completed. The resident was noted to have behaviors related to entering other residents’ rooms, invading others space and exit seeking often later in the day. The resident required one staff assistance for ADL care and was able to independently ambulate around the facility with a walker. The resident could make some needs known and had poor safety awareness. Review of the resident's records showed the following: * An incident investigation dated 12/05/24 indicated the resident was found to have discoloration to the right hand. The resident was unable to say what had caused the injury. Staff had no further information on the injury of unknown cause. The investigation indicated abuse and neglect was ruled out but contained no information on how that was done. The facility was asked to report the incident to the local SPD office and provided confirmation of the report prior to exit. The need to ensure all incidents were promptly investigated to rule out abuse and reported when required, was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 01/22/25 and 01/23/25. They acknowledged the findings.

1. Self-report made to SPD regarding resident 4’s discoloration to right hand on as identified through survey process. 2. All incidents requiring investigation will be investigated timely. Suspected abuse or abuse that is not able to be ruled out will be reported to SPD per Oregon Abuse and Reporting Guidelines. All-staff in-service conducted by 3/24/25 to review Oregon Abuse and Neglect Reporting guidelines, community process for investigating suspected abuse/neglect, timely reporting to SPD, and chain of command for process. Inservice conducted by 3/24/25 with designated staff regarding process for ruling out abuse and neglect and documentation. 3. Timely 4. WD, RN, AED

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services and was consistently implemented by staff for 3 of 3 sampled residents (#s 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease and edema. Observations of the resident, interviews with staff and review of the service plan, dated 01/17/25, showed the service plan was not reflective of the resident's current care needs, consistently implemented by staff and/or did not provide clear direction to staff in the following areas: * Aggression towards staff with care and agitation with spouse; * Private caregiver and facility staff roles/assistance levels; * Number of staff required for care and behaviors; * Toileting assistance and incontinent care; * Dressing, grooming and hygiene assistance; * Fall risks and resident placing themselves on the floor; * Safety interventions including low bed and a fall mat; and * Edema and elevating legs. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 01/23/25. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 06/2024 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 11/01/24, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented by staff and/or did not provide clear direction to staff in the following areas: * Toileting assistance and incontinent care; * Activities; * Exit seeking with difficult redirection; * Physical aggression with staff; and * Entering other residents; apartments and invading personal space. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 01/22/25 and 01/23/25. They acknowledged the findings. 3. Resident 2 moved into the facility in 09/2023 and had diagnoses including vascular dementia and osteoarthritis. Observations of the resident, interviews with staff, review of temporary service plans, progress notes from 10/21/24 through 01/21/25, and review of the service plan, dated 01/18/25, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Side rail on bed; * Evacuation ability; * Ability to use call system; and * Environmental factors that impact the resident’s behavior including noise. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 3 (Wellness Director) and Staff 7 (Resident Services Director) on 01/23/25. The staff acknowledged the findings.

1. Resident #3’s service plan was updated with current care needs and clear staff directions including agression towards staff with care and agitation with spouse; private caregiver and facility staff roles/assistance levels; number of staff required for care and behaviors; toileting assistance and incontinent care; dressing, grooming, hygiene assistance; falls risks and resident placing themselves on the floor; safety interventions including low bed and a fall mat; edema and elevating legs. Resident #4’s service plan was updated with current care needs and clear staff directions ncluding toileting assistance and incontinent care; activities; exit seeking with difficult redirection; physical aggression with staff; entering other residents apartments and invading personal space. Resident #2’s service plan was updated with current care needs and clear staff directions including side rail on bed; evacuation ability; ability to use call system; enviornmental factors that impacted the resident’s behavior including noise. 2. Residents will be evaluated prior completing service plans and service plans will be updated to reflect current care needs and clear direction to staff using provided template in electornic healthcare record per Oregon Administrative Rules. 3. Move-in, within 30-days, quarterly, significant change in condition 4. WD, RN, AED

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

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

Based on interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, and weekly progress documented until resolution for 2 of 4 sampled residents (#s 3 and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease and edema. The resident's 01/17/25 service plan, 10/17/24 through 01/20/25 progress notes, and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, lacked resident-specific directions to staff and/or interventions reviewed for effectiveness in the following areas: * Medication changes; * Resident to resident altercations; * Falls; and * Left arm bruising. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, provided clear, resident-specific directions to staff and interventions were reviewed for effectiveness was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 01/23/25. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease and edema. Observations of the resident, interviews with staff, and review of the resident's 11/01/24 service plan, 10/22/24 through 01/17/25 progress notes and physician communications were completed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, lacked resident-specific directions to staff and/or interventions reviewed for effectiveness in the following areas: * Toe discoloration and nail fungus; * Skin breakdown including blister on second toe of the left foot; * Medication changes; * Cough and cold symptoms; * Resident to resident altercation; and * Resident hit their hand/finger on bathroom bar. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, provided clear, resident-specific directions to staff and interventions were reviewed for effectiveness was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 01/22/25 and 01/23/25. They acknowledged the findings.

1. Resident #3 will be evaluated for medication changes, history/current resident to resident altercations, falls and left arm bruising. Unresolved changes will be placed on monitoring with documented progress notes at least weekly until resolve and include directions to staff or interventions reviewed for effectiveness. Resolved changes will be documented as resolved and service plan updated to reflect interventions and effectiveness of interventions. Resident #4 will be evaluated for toe discoloartion and nail fungus; skin breakdown including blister on second toe of the left foot; medication changes; cough and cold symptoms; resident to resident altercation; history of resident hittig her hand/finger on bathroom bar. Unresolved changes will be placed on monitoring with documented progress notes at least weekly until resolve and include directions to staff or interventions reviewed for effectiveness. Resolved changes will be documented as resolved and service plan updated to reflect interventions and effectiveness of interventions. 2. All short term changes in condition will be identified and monitored. All short-term changes of condition will have documentation of weekly progress until resolution, provide clear, resident specific directions to staff and include review of effectiveness of interventions. Direct Care inservice will be conducted by 3/24/25 regarding identification and monitoring of short term changes in condition. 3. Timely as identified, Weekly 4. WD, RSD, RN

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#3) who experienced significant changes of condition. Findings include, but are not limited to: Resident 3 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease and edema. Observations of the resident, interviews with staff, review of the service plan, dated 01/17/25, 10/17/24 through 01/20/25 progress notes, physician communications and hospice communications, and 09/02/24 through 12/19/24 weight records were completed. The resident required full assistance of 2-3 staff with his/her ADLs related to resistance to care. The resident was independent with meal intake and able to eat and drink without physical assistance from staff. The resident did intermittently require encouragement with his/her meals. The resident had significant confusion and was unable to consistently communicate needs. The resident’s dementia had progressed along with increased pain, care needs and behaviors. The resident was admitted to hospice services on 01/15/25. Multiple observations of the resident between 01/21/25 and 01/23/25 showed the resident seated in a chair in his/her apartment or laying in his/her bed. The resident spoke in word salad with intermittent full sentences and ate less than 50% of the meals observed. S/he was offered fluids throughout the day and attempts at snacks. The resident was in significant pain on 01/22/25 and 01/23/25, was provided prn medication for pain and was able to rest comfortably. S/he did not awaken for breakfast or lunch on 01/22/25. Weight records for 09/2024 through 12/2024 showed the following: * A weight of 125.8 pounds on 08/27/24 and a weight of 136.4 pounds on 12/19/24. This represented a 10.8-pound weight gain between 09/02/24 and 12/19/24, which constituted a 7.91% gain in three months. There were no weights recorded between September and December 2024 related to resident refusals and behaviors. The facility was no longer attempting to obtain weights on the resident since his/her admission to Hospice on 01/15/25. A weight at the time of survey was not attempted due to resident behaviors, decline and pain. The resident was not interviewed related to his/her dementia. In interviews between 01/21/25 and 01/23/25, Staff 9 (MT), Staff 10 (CG) and Staff 14 (CG) indicated the resident required multiple staff to complete ADL care due to cognitive impairment, resistance to care and refusals. The resident could eat and drink on his/her own once items were delivered. The staff stated the resident did need some encouragement with his/her meals and the resident’s intake was fair. The staff further indicated the resident was offered French toast whenever s/he would not eat much. The resident was almost always willing to eat the French toast. In interviews between 01/21/25 and 01/22/25, Witness 1 (Private CG) and Witness 2 (Family) indicated the resident’s meal intake varied; there were some days that were better than others. The resident loved French toast so that was always available to offer. They indicated the resident could eat and drink on his/her own but did need encouragement to eat and drink at meals and throughout the day. Witness 2 stated the resident received plenty of food and fluids within the context of what s/he would accept. The resident would not be forced to do anything or take anything s/he did not want. In an interview on 01/23/25, Staff 3 (Wellness Director) indicated she had made a note about the resident’s weights on 12/24/24. She did not note a significant gain between the September and December weights. Staff 3 stated she noted the resident had red swollen legs, had been refusing weights, and would not allow the LPN to check his/her lungs. Witness 4 further indicated there was no assessment completed by the RN. The current facility RN was brand new to the facility and had no further information to offer regarding the resident’s weight changes. The facility failed to ensure an RN assessment was completed for the weight gain which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 01/23/25. The staff acknowledged the findings.

1. RN will assess resident #3 regarding weight gain and document findings, resident status and interventions made as a result of the assessment. If resident not at baseline, RN will monitor, document resident status and interventions until new baseline established. 2. Resident weights will be obtained, documented and reviewed per company policy. All signticiant weight changes will be reported timely to Registered Nurse. Registered nurse will timely assess residents with signficant weight changes, documenting findings, resident status and interventions made as a result of the assessment. Registered nurse will monitor resident until return to baseline or new baseline obtained. 3. Timely as identified; Weekly until resolved/new baseliine obtained 4. RN

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

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

Based on interview and record review, it was determined the facility failed to ensure they had been consistently staffing to the posted staffing plan and failed to have a sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents. Findings include, but are not limited to: During the acuity interview on 01/21/25, the following was identified: * The facility was home to 26 residents in two segregated (North Shore and South Shore) secured units; * Eight residents (four residents each on the North Shore and South Shore units) required a two-person assist for transfers and/or ADL care; * Three residents required cueing, set-up, or feeding assistance; and * Ten residents were identified as having behavioral symptoms requiring staff assistance when having behaviors. On 01/23/25 at 10:15 am, the facility's Acuity Based Staffing Tool (ABST) entries, staff schedule, calculated staffing hours, and posted staffing plans were reviewed with Staff 1 (ED), Staff 3 (Wellness Director) and Staff 7 (Resident Services Director). The staffing plans posted by the facility “as of 01/18/25” was as follows: North Shore Day Shift: 6:00 am to 2:00 pm: One MT and three and a half CGs. Swing Shift: 2:00 pm to 10:00 pm: One MT and two and a half CGs. NOC Shift: 10:00 pm to 6:00 pm: Half MT and one CG. South Shore Day Shift: 6:00 to 2:00 pm: One MT and one and one and a half CGs. Swing Shift: 2:00 pm to 10:00 pm: One MT and One and a half CGs. NOC Shift: 10:00 pm to 6:00 am: A half MT and one CG. The staff schedule, dated 01/14/25 through 01/20/25, was reviewed. On 13 out of 42 shifts, the facility did not meet the posted staffing plan; in addition, the NOC shift failed to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. During interviews conducted on 01/21/25 through 01/23/25 identified the following: * Staff 13 (CG) reported there was not enough staff on the floor to take care of all the residents. *In an Interview on 01/21/25, Witness 2 (Resident 3 Visitor) and Witness 3 (Resident 3 Visitor) indicated staffing has been an issue. Witness 2 and 3 both visited multiple times a day, at all times of day, along with the resident’s spouse. They both stated night shift was a big concern, but the other shifts also did not have enough staff to meet all the resident needs. Witness 3 indicated there had been more than one occasion when there was only one staff on night shift covering the entire unit. The Witnesses both stated the staff available tried their best but there weren’t enough of them. The resident required at least two-person assistance for ADL care and could be resistive to care. Witness 3 further indicated a private caregiver was hired to help care for Resident 3 due to concerns with his/her ADL care. On 01/22/25 at 10:50 am Staff 1, Staff 2 (MC Administrator) via phone, Staff 3, Staff 4 (RN) and Staff 7 acknowledged the care minutes in facility’s ABST for one sampled Resident (#3), and three unsampled residents who required two person assistance was not accurate, and that the NOC shift staffing did not meet the minimum of two direct staff scheduled and available for residents requiring the assistance of two caregivers. The need to have a sufficient number of staff on all shifts to meet all scheduled and unscheduled needs of residents was discussed with Staff 1, Staff 2, Staff 3, Staff 4, and Staff 7 on 01/22/25. They acknowledged the findings.

1. ABST will be reviewed for all residents to ensure that ABST matches current resident needs as identified in service plans. Stafing plan will be posted to reflect ABST. Staff schedule will reflect staffing plan to ensure sufficient number of staff on all shifts to meet all scheudled and unsheduled needs of residents. 2. ABST will be updated timely with every change in service plan to reflect current service plan. Posted staffing plan will be reviewed with any change in service plan and ABST to ensure staff plan and ABST match. Staff schedule will then reflect posted staffing plan. 3. Before move-in; no less than quarterly; change of condition; corresponding to the service plan. 4. AED, WD, RSD

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

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

Based on interview and record review, it was determined the facility failed to ensure their Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements that staff were providing to residents. Findings include but are not limited to: A review of the facility’s ABST revealed the care time and care elements documented for cares provided by staff were not accurate for sampled Residents 3 and 4. During an interview conducted on 01/22/25 at 10:50 am with Staff 1 (ED), Staff 2 (MC Administrator) via phone, Staff 3 (Wellness Director), and Staff 7 (Resident Services Director), Staff 2 reported that three unsampled resident’s ABST did not have the correct number of minutes for provision of care related to the resident’s requiring two-person assistance with transfers and/or cares. On 01/23/25 the need to ensure the ABST accurately captured care time and care elements was discussed with Staff 1, Staff 3 and Staff 7. They acknowledged the findings. Staff 2 updated the ABST to more accurately reflect the resident’s care needs and updated the facilities staffing plan for each of the two separate secured units.

1. Resident #3 and Resident #4 will be evaluated to ensure that their service plan reflects resident current care needs. The ABST will be reviewed and updated as needed to reflect the service plan. 2. See C360 3. Before move-in; no less than quarterly; change of condition; corresponding to the service plan. 4. AED, WD, RSD

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

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

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: Six months of fire drill records were reviewed on 01/23/25 and revealed the following: a. Fire drills lacked documentation of one or more of the following components: * Date and time of day; * Location of simulated fire origin; * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. In an interview on 01/23/25 at 10:40 am, Staff 24 (Plant Operations Director) acknowledged the documentation lacked one or more of the required components. b. The facility failed to provide fire and life safety instruction to staff on alternate months. In an interview on 01/23/25 at 10:40 am, Staff 24 confirmed staff were not provided fire and life safety instruction on alternating months. The need to ensure fire drills were conducted according to Oregon Fire Code with all required components documented, and fire and life safety instruction to staff was provided on alternating months was discussed with Staff 1 (ED) on 01/23/25 at 2:51 pm. She acknowledged these findings

1. All fire drills conducted will include documentation of the following: date and time of fire drill; loaction of simulated fire origin; escape route used; problems encountered and comments relateing toe residents who resisted or failed to participate in the drills; evacuations time period needed; number of accupants evacuated. Fire and life safety instruction to staff was conducted on 01/30/25. 2. Documentation for fire drills will be updated to include required components. A schedule will be created for Fire and Life Safety instruction to staff for alternating months. 3. Monthly 4. POD, AED

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

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

Based on interview and record review, it was determined the facility failed to ensure each resident was instructed within 24 hours of admission and re-instructed at least annually in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of a fire. Findings include, but are not limited to: Resident fire and life safety training records were reviewed on 01/23/25 and revealed multiple unsampled residents did not receive fire and life safety instruction within 24 hours of admission or annually. In an interview on 01/23/25 at 10:55 am, Staff 24 (Plant Operations Director) confirmed he was “behind” on instruction to residents at move-in and annually. The need to ensure each resident was instructed within 24 hours of admission and re-instructed at least annually in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of a fire was discussed with Staff 1, (ED) on 01/23/25 at 2:51 pm. She acknowledged these findings.

1. All resident records will be reviewed and those lacking admission or annual fire and life safety training will receive training regarding general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of a fire. 2. Resident Fire and Life Safety training will be completed upon admission and annually. Schedule will be placed for annual Fire and Life Safety training. All new admissions will be scheduled and coordinated to ensure timely completion of resident training within 24 hours of admission. Review of documentation will occur to ensure compliance. 3. Upon admission; Monthly; Annually 4. POD, AED

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

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry (b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.

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 when washing soiled linens. Findings include, but are not limited to: The facility soiled linen room was toured on 01/23/25 and interviews with staff were completed and revealed the following: During interviews with Staff 10 (CG) and Staff 19 (CG) on 01/21/25 they stated incontinent linen was bagged up, taken to the incontinent laundry room, rinsed in the flushing rim sink, and washed in the small washer with detergent added by pressing a button/using the metered detergent. The washing process was confirmed by Staff 8 (Environmental Services Director) on 01/23/25 at 10:03 am who confirmed the laundry detergent did not contain a chemical disinfectant. Staff 24 (Plant Operations Director) and this surveyor took the temperature of the water line feeding into the incontinent laundry room on 01/23/25 at 10:17 am. Over two separate readings, the water reached 120 degrees F and 121.3 degrees F, or nearly 20 degrees less than the required 140 degrees F needed when washing soiled linens without a chemical disinfectant. The need to ensure washers had a minimum rinse temperature of 140 degrees F unless a chemical disinfectant was used was reviewed with Staff1 (ED), on 01/23/25 at 2:51 pm. She acknowledged these findings.

1. A chemical disinfectant will be added to water temps less than 140 degrees F when washing all soiled linen. 2. From this point forward, the system is corrected by the addition of a chemical disinfectant added to all water temps less than 140 degrees F when washing soiled linen. All direct care staff and house keeping staff will be inserved by 3/24/25 regarding use of chemical disinfectant when washing soiled linens. System will be reviewed for compliance. 3. Monthly 4. Environmental Services Director; POD

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry (b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.

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

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to no locks on bathroom doors for residents who had shared bathrooms. Findings include, but are not limited to: Observations on 01/21/25 of shared bathrooms revealed there was no locking mechanisms on shared bathroom doors to ensure privacy. On 01/23/25, the observations and the need to ensure shared bathroom doors had locks were reviewed with Staff 1 (ED), Staff 2 (MC Administrator) via phone, Staff 3 (Wellness Director), Staff 4 (RN), and Staff 7 (Resident Services Director).

1. All resident shared bathroom doors will be updated with locking mechanism to ensure privacy. 2. System will be corrected once locking mechanism is installed. Unscheduled maintenance will be performed as needed. 3. Timely for unscheduled maintenance 4. POD

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

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to the absence of locks on bathroom doors for residents who shared bathrooms. This is a repeat citation. Findings include, but are not limited to: In an interview on 07/01/25, Staff 1 (ED), reported that locks had not yet been installed on bathroom doors that were shared by residents. Observations during the survey confirmed that there were no locking mechanisms on shared bathroom doors to ensure privacy. On 07/02/25, the need to ensure shared bathroom doors had locks was reviewed with Staff 1 (ED), Staff 25 (MC Administrator), and Staff 26 (Wellness Director). They acknowledged the findings.

Refer to H1517

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

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to the absence of locks on bathroom doors for residents who shared bathrooms. This is a repeat citation. Findings include, but are not limited to: In an interview on 07/01/25, Staff 1 (ED), reported that locks had not yet been installed on bathroom doors that were shared by residents. Observations during the survey confirmed that there were no locking mechanisms on shared bathroom doors to ensure privacy. On 07/02/25, the need to ensure shared bathroom doors had locks was reviewed with Staff 1 (ED), Staff 25 (MC Administrator), and Staff 26 (Wellness Director). They acknowledged the findings.

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

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

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231, C360, C362, C420, C422, C530, and H1517.

Refer to C231, C360, C362, C420, C422, and H1517

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

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer H1517.

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

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer H1517.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly hired staff (#s 20 and 22) completed all required pre-service orientation prior to performing any job duties, 2 of 4 long-term direct care staff (#s 9 and 17) lacked 16 hours of annual in-service training, including six hours related to dementia care, and 6 of 6 long-term staff (#s 7, 9, 15, 16, 17, and 18) lacked infectious disease training. Findings include, but are not limited to: Staff training records were reviewed on 01/23/25. The following deficiencies were identified: 1. Staff 20 (CG) and Staff 22 (CG) hired 09/26/24 and 11/12/24, respectively, failed to have documented evidence of completing one or more of the following pre-service orientation trainings prior to beginning job duties: * Infectious Disease Prevention; * Approved HCBS course; and * Approved LGBTQ2S+ course. 2. Staff 17 (CG), and Staff 9 (CG), hired 04/12/17 and 09/22/22, respectively, failed to have documented evidence of the required 16 hours of annual training, including six hours of dementia care training. 3. Staff 7 (MT), Staff 9, Staff 15 (Life Enrichment Director), Staff 16 (Housekeeper), Staff 17, and Staff 18 (CG) failed to have documented evidence of the required annual infectious disease training. The need to ensure newly hired staff completed all required pre-service orientation prior to performing any job duties, and long-term staff completed the 16 hours of required annual in-service training, including six hours of dementia care training and/or infectious disease training was reviewed with Staff 1 (ED), on 01/23/25 at 2:51 pm. She acknowledged the findings, and no additional documentation was provided.

1. All staff training files will be audited for required pre-service orientation training including infectious disease prevention; approved HCBS course and approved LGBTQ2S+ course. All staff files will be audited for the required 16 hours of annual training, including six hours of dementia care training and annual infectious disease training. All staff identified with missing training will have training assigned and completed. 2. All staff will complete the required pre-service orientation prior to performing job duties. Training documentation will be reviewed prior to staff performing job duties or being scheduled for shifts. Tracking tool will be implemented to track annual trainings and reviewed for compliance. 3. Prior to performing job duties; quarterly; annually 4. BOM, RSD, AED

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

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

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C260, C270, and C280.

Refer to C260, C270, and C280

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

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records 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 the facility had fully evaluated and developed individualized plans based on the residents’: * Current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate in activities; and * Identified activities for behavior interventions. There were no specific individualized activity plans which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities. On 01/23/25, the need to ensure residents were evaluated and had an individualized activity plan was discussed with Staff 1 (ED), Staff 2 (MC Administrator), Staff 3 (Wellness Director), Staff 4 (RN), and Staff 7 (Resident Services Director). They acknowledged the findings.

1. Residents #1, #2, #3 and #4 will have full evaluation with developed individualized person-centered plans based on their respective: current interests; current abilities and skills; emotional and social needs and patterns; physical abilities and limitations; adaptions necessary for the resident to participate in activites; and identify activites for behaviour interventions. Individualized activity plans will include detailed what, when, how and how often staff should offer and assist each resident with individualized activity. 2. All residents will be evaluated according to licensing rules prior to admission and as needed for meaningful activities that promote or help sustain physical and emotional well-being. Individualized activity plans will be developed based off initial evaluation and evaluated/updated with all service plan updates or changes in condition to ensure plan still promotes and sustains the residents physical and emotional well-being. 3. Upon move-in, quarterly, change in condition, corresponding to service plan. 4. WD, RSD, LED, AED

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

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

Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to H1517.

Waterford Grand MC has barn doors in its memory care community and it has been having difficulty finding a solution for adding single lever action locks as required by HCBS rules. It has previously received an extension to compliance and requested an additional extension while OHCA and ODHS negotiate a solution for those communities where adding a lock is not reasonably feasible. Waterford has never heard back regarding the request for an additional extension. Re-survey took place on July 1 and 2, 2025 while we are still waiting to hear about our request. It is our understanding that ODHS is actively working with OHCA on this issue.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure each resident's dignity with dining was maintained by failing to ensure resident likes and preferences with meals were honored, along with ensuring wait times for meals were reasonable for 1 of 1 sampled resident (#1). Findings include but are not limited to: Resident #1 was admitted to facility on 11/09/17 with diagnoses including major depressive disorder and Alzheimer's disease. The resident's diet order, dated 09/27/23, was regular/general/house diet, mechanical dental soft: ground texture, and thin/regular consistency. The resident face sheet indicated his/her spouse was his/her Power of Attorney for financial and care decisions and listed the resident's daughter as emergency contact number two. The resident's service plan was reviewed and documented the following: * Eating/Meals - Initiated 08/16/22, revised 01/09/24: "[Resident name] requires staff assistance in ordering or choosing menu items...[Resident name] enjoys soft foods...due to missing teeth. serve milk with every meal per family request. [Resident] enjoys breakfast foods such as scrambled eggs, French toast, and pancakes..." * Diet - Initiated 08/16/22, revised 04/04/24: "Diet - Mechanical Soft Diet: Ground. Daughter would like input in [his/her] menu Choices, Make this available to her. High protein choices when she is not available. Breakfast choose eggs and sausage, NO pancakes, french toast or syrup on [his/her] plate. Lots of meat few carbs and make sure vegetables are bite size portions." Progress notes documented on 04/04/24, "Care conference held today with daughter. Daughter does not want syrup or pancakes, high protein. Meats should be chopped more..." On 08/08/24, during the facility's annual kitchen inspection, the lunch meal was observed. The meal cart from the kitchen arrived to the South unit, where Resident 1 resided, at approximately 11:10 am. At 11:35 am, caregivers began dishing out resident meals. Surveyor observed staff dish out three plates of pureed menu choices. Surveyor asked how many residents received altered texture diets. The staff response was one puree and two mechanical soft. Surveyor asked why three plates of puree were dished out, and the staff member replied that there were no mechanical soft items sent from the kitchen that meal. Staff decided not to serve the pureed texture to Resident 1, but stated they would contact the kitchen for a mechanical soft meal. Resident 1 was sitting at the table with beverages at this time. At 12:25 pm, the resident was observed still at the table with beverages, but no food. Surveyor asked care staff if kitchen had provided any mechanical soft food items yet, to which they replied, "No, not yet." Surveyor went to main kitchen and observed three containers of mechanically altered food items sitting on the warming line ready for service. Surveyor observed line cook asking another kitchen staff to take the mechanically altered items to memory care. Surveyor followed food items to South unit. Care staff immediately began dishing up a serving of finely chopped carrots, mashed potatoes, and finely diced/ground BBQ meat into one bowl. Staff was then observed to open a container of applesauce and pour over meal items and mix entire content of bowl together. Surveyor asked care staff if that was how Resident 1 preferred his/her meals. Staff replied, "No, this is what [his/her] daughter wants us to do." Surveyor asked staff if they knew why, and they replied, "No, but it's gross. [Resident] doesn't eat it. Maybe [his/her] daughter wants [him/her] to have more fruit?" Staff then stated that the daughter "makes" them serve all the resident's meals like this with all food items mixed together with applesauce. Staff also indicated they are not allowed to give the resident pancakes or French toast at breakfast, which the resident likes. Per the resident's daughter, they were to serve only "scrambled eggs, bacon, and/or sausage with apple sauce mixed in. It's so gross, [s/he] never eats it." Resident 1 was served his/her lunch at 12:35 pm, an hour after other residents were served their meal. On 08/08/24 at 12:45 pm, Staff 2 (Dining Services Director) was interviewed regarding the extended time for mechanical soft to be provided to Resident 1. Staff 2 stated that one hour was definitely too long and not typical. Staff 2 was not sure why pureed items were originally sent for all mechanically altered residents and agreed that was not appropriate. Staff 2 indicated that the line cook that usually takes care of the mechanically altered items was "slammed" that meal service and acknowledged that the kitchen should have gotten the right textured food to the resident more quickly. Staff 1 (Executive Director) and Staff 5 (Memory Care Administrator) were interviewed on 08/09/24 at 11:10 am. Both acknowledged that Resident 1 waiting an hour to receive their mechanically altered food items was unacceptable. Neither Staff 1 nor Staff 5 were aware that staff were combining all of the resident's food items and mixing in applesauce at all meals. Both Staff 1 and Staff 5 acknowledged that practice was not appetizing, with a high potential for the food to not be palatable for most individuals. Staff 1 and Staff 5 were asked to provide documentation that Resident 1's daughter was power of attorney to make care decisions for him/her. No documentation could be located prior to survey exit. Both Staff 1 and Staff 5 acknowledged that the resident had a right to eat foods that they liked and in a way that they liked/preferred. Staff 1 acknowledged that Resident 1 did not have any medical diagnoses that would indicate the need for a reduced carbohydrate and high protein diet. Staff 1 acknowledged there was no diet order to indicate that a carbohydrate restricted diet would be appropriate for the resident.

C200 The following actions will be taken to correct the violations: An audit of all MC resident's diet orders will be completed by the AED/WD/RSD to itentify and address any discrepancies or errors Inservice training session will be conducted by DSD with all dining associate on preparing special texture diets, and the importance of safety for residents requiring special dietary needs. This to include a hands-on demonstration of preparing puree and mechanical soft textures to help with ensuring accuracy and consistency. Inservice training session with ALL associates reviewing the key rights guaranteed to residents, including the right to be treated with respect, privacy, and dignity. Inservice training session will be conducted by DSD with all dining associates on timeliness of order processing, preparation, and delivery Inservice training session with all MC associates regarding POA, where to find the POA information, and that a POA is the designated individual with the authority to act on behalf of the resident Diet board created identifying which residents have a special texture diet.  The board will be visible in the main kitchen to all dining associates.  It will be maintained by the DSD/WD

Based on observation, interview, and record review, it was determined the facility failed to ensure each resident's dignity with dining was maintained by failing to ensure resident likes and preferences with meals were honored, along with ensuring meals were appetizing/palatable for 1 of 1 sampled resident (#1). This is a repeat citation. Findings include, but are not limited to: Resident 1 was admitted to facility on 11/09/17 with diagnoses including major depressive disorder and Alzheimer's disease. Resident 1 was non-interviewable. A Faxed copy of "health care provider's orders" dated 09/11/24 documented: "Please confirm the diet we have on file: Mechanical soft, decreased carbs, increased protein. Food in bowl & (and) apple sauce added. Regular thin, liquids...Do you agree?" The box of "yes" was marked and the statement, "agree to above," was documented. The resident's service plan was reviewed and documented the following: * Eating/Meals - Initiated 08/16/22, revised 01/09/24: "[Resident name] requires staff assistance in ordering or choosing menu items...[Resident name] enjoys soft foods...due to missing teeth. serve milk with every meal per family request. [Resident] enjoys breakfast foods such as scrambled eggs, French toast, and pancakes..." A addition on 08/22/24 documented "Resident requires hands on assistance to complete meal (Specify:)." * Diet - Initiated 08/16/22, revised 04/04/24: "Diet - Mechanical Soft Diet: Ground. Daughter would like input in [his/her] menu Choices, Make this available to her. High protein choices when she is not available. Breakfast choose eggs and sausage, NO pancakes, french toast or syrup on [his/her] plate. Lots of meat few carbs and make sure vegetables are bite size portions." On 10/10/24 at 11:45 am  Resident 1 was observed with lunch meal served. The resident had a large bowl of ground food products in front of her that she was feeding herself. The food products were all of similar color and texture. Care staff were interviewed and stated that they were directed to put all food items in one bowl and mix in a container of applesauce for all meals. Staff were asked if that was the resident's preference and they stated it was not, that it was directed from the resident's daughter. On 10/10/24 at 12:45 pm, Staff 2 (Dining Services Director) was interviewed and was asked why all food items for Resident 1 were served in the same bowl, mixed all together with applesauce. Staff 2 indicated to her knowledge it was related to the wishes and direction of the resident's daughter. Staff 2 acknowledged that serving foods all blended together with applesauce would not be appealing/palatable to most people. Staff 2 verified to their knowledge that was not a preference for the resident to have her meals delivered in this way. Interview with Staff 3 (Business office manager) and Staff 4 (Resident services director) at 1:00 pm revealed the reason staff combined all meal/food items together was related to the daughter insisting the meals be served that way. Staff were not able to provide any documentation or other evidence to support the mixing of food items was the residents choice. They acknowledged that they themselves would not wish to consume their meals in this manner. Staff 3 and Staff 4 were asked why there was a carbohydrate restriction for the resident. They confirmed it was at the request of the daughter. Staff 1 (Executive Director) and Staff 5 (Memory Care Administrator) were interviewed 10/11/24 at 10:00 am. Both acknowledged that they were aware that staff were combining all of the resident's food items and mixing in applesauce at all meals. Both Staff 1 and Staff 5 acknowledged that practice was not appetizing, with a high potential for the food to not be palatable for most individuals. Staff 1 and 5 confirmed the facility had not attempted alternatives to the mixing food together for meals to increase independence with eating. Staff 1 and 5 acknowledged the facility continued to restrict access to carbohydrate rich foods including those identified per resident likes that the resident enjoyed at the request of the resident's daughter. The facility failed to ensure Resident 1's right to eat the foods they enjoy/liked by restricting carbohydrates as well as, the right to receive food in a way that was appetizing and palatable.

The following actions will be taken to correct the violations: 1. Resident 1 service plan was updated with likes and preferences for meals; Hospice clarified texture, and how to present it in a way that is appetizing and palatable. Care conferences were held with family and POA on 10/14/24 and 10/17/24 to review resident #1 dining preferences and resident right to receive food that is appetizing and palatable. On 10/17/24, two in-services were conducted with memory care associates to review and educate about Residents Rights and Protections, OAR 411-054-0027. Dietary boards in memory care kitchens and main kitchen were updated with current diet and texture orders. 2. The system will be corrected by the following steps and to assure it doesn't happen again: We obtained current diet and texture orders for all memory care residents and entered diet orders into electronic health care record. 3. Diet orders will be reviewed weekly. 4. Dining Services Director, Associate Executive Director, and Executive Director, and Licensed Nurse will be responsible to see that the corrects are completed and monitored.

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 main facility kitchen and the memory care unit kitchenettes on 08/08/24, from 10:15 am through 1:45 pm, revealed the following deficient practices: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Removable hood vents; * Floors in corners and edges throughout kitchen; * Floor under and behind major equipment; * Floor under and around ware washing area; * Walls behind and beside grill, flat top, and fryer; * Corners, edges, and front of gas flame grill; * Interior and exterior of convection oven; * Industrial slicer; * Table top equipment (blender/food processor); * Industrial mixer; * Walk-in freezer and cooler floors; * Metal racks holding meat products in walk-in cooler; * Movable "Go" racks in walk-in: * Metal utility cart holding fan; * Fan blades, cage, and base; * Open stainless steel shelving throughout kitchen; * Reach-in coolers and freezers; * Wall under hand washing sink; * Ice scoop holder; and * Door grate for elevator floor off of main kitchen leading to dry storage/memory care unit with heavy food/dirt debris noted in crevices. b. The following areas needed repair: * Sections of caulking in ware washing area with black matter debris and build-up; * Deli fridge plastic door striping damaged and peeling off; and * Holes by duct work in dry storage with greater than 1/4 inch gap needing to be sealed to prevent potential pest entry. c. Dietary employee observed to serve hot dogs off the grill without checking temperature to ensure they reached the required 165 degrees. Surveyor asked employee to check temperature and both hot dogs were above 165 degrees; however, the kitchen employee was going to serve the food product to residents without first validating the appropriate and safe temperature was reached. d. Multiple dietary employees were handling clean dishes or preparing food without appropriate hair or facial hair restraints. e. Multiple food items were found uncovered/unprotected from potential contamination while stored in reach-in and/or walk-in coolers or freezers. f. Multiple food items were found without open dates and/or without use-by dates or past seven days per food code. g. Staff lunch container was noted to be stored in reach-in refrigerator storing resident food. h. North unit kitchenette revealed areas in need of cleaning: * Microwave and reach-in oven with dried food debris, spills, and splatters; * Multiple items located in reach-in refrigerator were not dated when opened or were noted to be past the seven days; and * One opened container of cottage cheese was past seven days and had visible mold growth on/in food product. i. South unit kitchenette revealed the following areas in need of cleaning: * Reach-in refrigerator with spills, splatters, and food debris; * Oven with dried on-food debris; * Reach-in refrigerator with multiple undated food items; and * Staff food/beverages stored with resident food. Staff 2 (Dining Services Director) toured the area with surveyor and acknowledged areas in need of cleaning and attention. In an interview on 08/08/24, at 1:45 pm, Staff 1 (Executive Director) was informed of concerns found and acknowledged areas needing correction.

C240 The following actions will be taken to correct the violations: a. The following items have been thoroughly cleaned *Removable hood vents *Floors in corners and edges throughout kitch *Floor under and behind major equipment *Floor under and behind ware washing area *Walls behind and beside grill, flat top, and fryer *Corners, edges, and front of gas flame grill *Interior and exterior of convection oven *Industrial slicer *Table top equipment (blender/food processor) *Industrial mixer *Walk-in freezer and cooler floors *Metal racks holding meat products in walk-in cooler *Movable "Go" racks in walk-in Metal utility cart holding fan *Fan blades, cage, and base *Open stainless steel shelving throughout the kitchen *Reach-in coolers and freezers *Wall under handwashing sink *Ice scoop holder *Door grate for elevator floor off of the main kitchen All of the above items will be monitored weekly by Dining Services Director/AED/ED b. The following areas have been repaired: *Sections of caulking in ware washing area completed by POD *Deli fridge plastic door stripping replaced by Clay's Refrigeration *Holes by duct work in dry storage were sealed by POD to prevent potential pest entry c. Inservice training session will be conducted by the DSD with all dining associates on food safety, proper temperature usage, key temperature guidelines, and best practices when serving food d. Inservice training session will be conducted by DSD with all dining associates on food safety, why hairnets and facial restraints are crucial, proper usage, and best practices. DSD/AED/ED will monitor daily for compliance e. Inservice training session will be conducted by DSD with all dining associates on food storage safety, proper labeling and covering of all items stored in the freezer and/or walk-in cooler.  DSD/AED/ED will monitor daily for compliance f. Inservice training session will be conducted by DSD with all dining associates on food storage safety, proper labeling and covering of all items stored in the freezer and/or walk-in cooler.  DSD/AED/ED will monitor daily for compliance g. Inservice training session will be conducted by DSD with all dining associates on proper food storage and potential cross contamination when associate lunch containers are stored in designated resident refrigerators .  DSD/AED/ED will monitor daily for compliance

Based on interview and record review, it was determined the facility failed to ensure 2 of 8 staff (#s 3 and 4) who prepared food had active food handler's certificates. Findings include, but are not limited to: On 08/08/24 employee records were requested and reviewed to ensure staff had active food handler's cards. The food handler's card for Staff 3 (Cook) was dated as obtained the day of survey. No food card was provided for Staff 4 (Cook). In an interview with Staff 1 (Executive Director) on 08/08/24 at 2:40 pm, surveyor requested to review Staff 3's previous food handler's card of Staff 3 and again requested Staff 4's food handler's card to review. On 08/09/24 at 11:10 am, the facility provided a copy of Staff 3's former food card, which had expired on 11/06/23. An active food card still could not be located for Staff 4. Staff 1 acknowledged Staff 3 and Staff 4, who prepared food, did not have active food handler's cards upon entry for annual kitchen survey.

An audit of associate records will be conducted by the ED and Business Office Manager.  A tracker will be created and maintained by the BOM.  It will be monitored weekly by the ED/AED/DSD

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 200, C 240, and C 370.

Refer to C200, C240, C370

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 C 240.

Refer to C200 and C455

Based on interview, observation, and review of records, 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 200.

Refer to C200

The findings of the kitchen inspection, conducted 08/08/24 through 08/09/24, 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 08/09/24, conducted 10/10/24 through 10/11/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 08/09/24, conducted 01/02/25, 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, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the memory care kitchenette on 07/28/23 at 11:00 am through 3:00 pm revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Interior of ice machine with black/mold like substance; and * Interior of oven in South kitchenette. b. No designated hand washing sink available in North kitchenette. Dirty dishes were stacked in both sinks. c. No sanitizing method available to sanitize thermometer between checking food temperatures before service. Observed temperatures not at required 135 degrees F thus potentially contaminating fully cooked products with potentially undercooked products. d. Multiple food items observed not at 135 degrees F for service. Upon review of temperature records for service for 30 days, there were 27 times hot entrees were recorded below 135 degrees F. There were another 33 meals where no temperature was recorded for the meal. e. Plate of sandwiches served from lunch along with plated mechanical plates for residents were observed sitting on counter top in South kitchenette at 2:00 pm. They were brought to the kitchenette at 11:15 am. Upon interview with Staff 2 (Food Service Director) s/he acknowledged the expectation would to have placed those items immediately in the refrigerator after meal service. f. Staff serving/plating food for North unit were observed to dish up food, touch RTE (ready to eat) sandwiches, serve plates and drinks to residents, then return to plating up dishes with same pair of gloves. This practice potentially contaminated the ready to eat products and not in compliance with single use glove use where gloves are for one task only. At approximately 3:00 pm, the surveyor reviewed above areas with Staff 1 (Executive Director) Staff 2 (Food Service Director) and Staff 3 (Administrator) They acknowledged the identified areas.

C240 The following actions will be taken to correct the violations: a. Interior of ice maching is professionally cleaned monthly by an outside provider. Dining Services Director/AED will monitor weekly for compliance. Interior of oven in South kitchenette will be deep cleaned and monitored weekly by Dining Services Director/AED. b. A separate dish tub will be purchased and used to place dirty dishes until they are washed.  This will free up a sink for designated hand washing.  DSD/AED/AWD/RSD will monitor daily for compliance. c. Thermometers will be cleaned using an alcohol swab inbetween ensuring that each food item is at the correct temperature.  DSD/AED/AWD/RSD will monitor daily for compliance. d. Identified the thermometers being used were not functional.  New thermometers purchased immediately and implemented.  Temperature logs will be monitored daily by DSD/AED/AWD/RSD. e. All cold items are place in the refrigerator after each meal service.  DSD/AED/AWD/RSD will monitor daily for compliance. f. Inservice will be conducted with MC associates on proper glove usage and service temperatures. Associates will change gloves inbetween preparing  ready to eat foods.  DSD/AED/AWD/RSD will monitor daily for compliance.

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.

Refer to C240

The findings of the kitchen inspection, conducted 07/28/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 07/28/23, conducted 10/09/23, 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.

The findings of the on-site investigation, conducted 06/29/23 through 06/29/23, 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, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:             Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on observation, interview, and record review, 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. Findings include, but are not limited to: Observations of the facilities kitchen, food storage areas, food preparation, and food service on 08/16/22 revealed: * Splatters, spills, debris, and drips noted on: - Can opener blade and casing; - Shelving; - Food storage and delivery carts; and - Interior of the ovens. * Food was stored on the floor of the freezer. * Scoops were left in bins of food. * Undated and unlabeled food items were noted in the reach in and walk in refrigerators. * Residential dishwasher were being used in the Memory Care units. Commercial dishwashers are required with a capacity over 16 residents. * The wiping cloth sanitizer bucket was not monitored to ensure the sanitizer was dispensing at the correct parts per million, staff were not aware of where to locate the test strips. * Staff were observed to not change gloves between tasks during the plating of food for breakfast. * Caregiving staff plating and serving food were not using aprons. * The doors to the food preparations area and the warewashing area were open allowing for the entry of multiple flies. The kitchen was reviewed with Staff 1 (Administrator) and Staff 2 (Dietary Services Manager). They acknowledged the findings.

1) The following actions will be taken to correct the violations: a. Can Opener blade casing, shelving, interior of oven and food storage and delivery carts have been cleaned. Food boxes were removed from the floor, scoops were removed from bins Undated/unlabeled food was thrown out in walk in refrigerators Residential dishwashers will no longer be used All sanitizer buckets were emptied and refilled Proper glove wearing was discussed Proper Apron use was discussed Screens for trailer doors have been ordered 2) System will be corrected by the following: a. Items above needing cleaned were added on the daily/weekly/monthly cleaning checklist b. All deliveries will be monitored to keep food boxes from being stored on the floor.  Director of Dining Services will monitor this daily and delegate this task when not in the community.  This topic will also be addressed in an inservice with all dining associates c. Scoops in bins-Director of Dining Services will monitor this daily and delegate this task when not in the community.  This topic will also be addressed in an inservice with all dining associates d. Dining Associate inservice on dating and labeling of all food will be completed e. Residential dishwashers will not be used.  Signs have been hung on them directing associates not to use them d. An Inservice will be conducted with kitchen associates on proper gloves wearing proper apron wearing, and checking PPM with strips and where strips are stored c. Screens for the trailer doors have been ordered and are being installed to keep flies out.  Orkin Pest control also came and sprayed around trailers to prevent flies 3) The Systems to ensure that food is prepared and served in accordance with the Oregon Food Sanitation Rules, including cleaning, repairs, proper safe food handling practices, and infection control procedures, will be evaluated by the Dining Services Director and the Executive Director weekly. 4) The Dining Services Director and/or the Executive Director will be responsible for overseeing that the above systems are in place and monitored daily

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

Refer to C 240

The findings of the kitchen inspection, conducted 08/16/22, 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 Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 8/16/22, conducted 2/28/23, 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 interview and record review, it was determined the facility failed to ensure all incidents and injuries of unknown cause were investigated to rule out abuse and reported to the local SPD as suspected abuse when abuse was not reasonably ruled out for 1 of 3 sampled residents (# 2) who experienced incidents or sustained injuries of unknown cause.  Findings include, but are not limited to: Resident 2 was admitted to the facility in April 2020 with diagnoses including dementia. Review of Resident 2's progress notes and incident investigations from 4/27/21 through 7/25/21 revealed Resident 2 experienced injuries of unknown cause which were not immediately or thoroughly investigated to rule out abuse or reported to the local SPD as suspected abuse on: * 5/15/21: Skin tear to right elbow; and * 6/15/21: Skin tear to left lower leg. The need to ensure all incidents and injuries of unknown cause were immediately and thoroughly investigated to rule out abuse and reported to the local SPD if abuse could not be reasonably ruled out was discussed with Staff 1 (Administrator) on 7/28/21. Survey requested the facility report the injuries of unknown cause to the local SPD. A fax confirmation of the report was provided prior to exit on 7/28/21.

1. Resident 2 - Injury sustained has been investigated and documented. APS was notified on 7/28/21. 2. All injuries of unknown cause will be thoroughly investigated immediately to rule out abuse and neglect. All incidents that cannot rule out abuse/neglect will be reported immediately to APS. 3. Weekly 4. MCD and administrator

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 and provided clear direction to staff for 3 of 4 sampled residents (#s 1, 2 and 4). Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in November 2020 with diagnoses including dementia and osteoarthritis. The resident's service plan dated 4/24/21 was not reflective of the resident's current care needs and did not provide clear direction to staff  in the following areas: * Transfers; * Ambulation and Mobility; * Toileting assist; * Bathing/showering assist; and * Evacuation assistance.   The need to ensure resident service plans were reflective of current care needs and provided clear directions to staff was discussed with Staff  1 (Administrator), Staff 3 (RN), Staff 4 (LPN) and Staff 5 (LPN). The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in April 2020 with diagnoses including dementia. Review of Resident 2's 5/27/21 service plan revealed it was not reflective of the resident's care needs and did not provide clear direction to staff in the following areas: * Transfers; * Meal assist; and * Non-verbal indicators of pain and anxiety. The need to ensure the resident's service plan was reflective of his/her care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Executive Director) on 7/28/21. They acknowledged the findings. 3. Resident 1 was admitted to the facility in October 2018 with diagnoses including dementia. A review of Resident 1's service plan, dated 6/16/21, revealed it was not reflective of the resident's needs and did not provide clear instruction to staff in the following areas: * Transferring; * Toileting assist; and * Dressing. The need to ensure the service plan accurately reflected the resident's needs and provided clear direction to staff for the provision of services was discussed with Staff 1 (Administrator) on 7/28/21. She acknowledged the findings.

1. Resident 4's evaluation and service plan have been updated with missing care needs and directions for staff regarding transfer, ambulation and mobility, toileting assist, bathing/showering assist and evacuation assist.  Care conference scheduled. The updated service plan is in the service plan book. Resident 2's evaluation and service plan have been updated with missing care needs and directions to staff for transfer; meal assist and non-verbal indicators of pain and anxiety. Care conference was scheduled and the updated service plan is in the service plan binder. Resident 1's evaluation and service plan have been updated with missing care items and directions for staff regarding transferring, toileting assist and dressing. 2. Service plans will be created prior to move-in, based on the initial evaluation. The initial service plan is created by the Wellness director or nurse. The facility will review all new move-in service plans at 30 days, 90 days and for significant changes in condition.  Corrections and/or additions to the service plan will be decided on by the nurse or RN. The RSD, med techs, and care staff will be retrained regarding reviewing service plans. 3. Move-in, 30 day, 90 day or significant changes 4. Wellness Director and MCD

2. Review of Resident 2's facility record and 4/27/21 through 7/27/21 progress notes revealed the following: a. Resident 2 experienced the following changes of condition that were not monitored at least weekly through resolution: * Bruise on left shin; * Urinary tract infection with antibiotic treatment; and * Hematoma on forehead. b. Resident 2 experienced four falls between 7/8/21 and 7/26/21. The resident's 5/27/21 service plan indicated he/she had a history of falls and instructed staff to perform three to four visual checks per shift with toileting as needed and to park the resident's wheelchair by the bed. The facility failed to investigate the circumstances for each fall to determine if the service-planned interventions were implemented, were effective or if new interventions were needed. The need to ensure short-term changes of condition were monitored through resolution and service planned interventions monitored for effectiveness related to falls was discussed with Staff 1 (Administrator) and Staff 2 (Executive Director) on 7/28/21. They acknowledged the findings.

Based on record review and interview, it was determined the facility failed to ensure short-term changes of condition were monitored and progress documented as least weekly through resolution and the effectiveness of interventions was monitored, for 2 of 4 sampled residents (#s 1 and 2) who experienced changes. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in October 2018 with diagnoses including dementia.   Resident 1's service plan noted he/she had a history of and was at risk for falls and instructed staff to assist with transfers and ADLs as needed and to check the resident frequently when he/she was in their room. A review of the resident's record revealed he/she experienced falls on 11 occasions between 4/25/21 and 7/19/21. There was no documented evidence interventions were monitored for effectiveness after each fall. The need to monitor the effectiveness of interventions for changes of condition was discussed with Staff 1 (Administrator) and Staff 2 (ED) on 7/28/21. They acknowledged the findings.

1. Resident 1's fall history was reviewed, and service plan will be updated with effective fall interventions: Resident has tab alarm in place to alert staff when resident is getting up on her own. Resident has hospital bed, when resident is in bed have bed in lowest position. Staff to toilet resident before putting resident into bed. Offer resident a snack before bedtime.    Resident 2's fall history was reviewed, and service plan updated with effective fall interventions. Tab alarm, in place alerts the staff. Staff to take resident to bathroom before placing resident in bed. Offering a snack, have been effective to date. As last noted fall was 7/28/2021  Service plan has been updated to reflect history of changes in condition including history of bruising, UTI with antibiotic treatment and hematoma on forehead. In-service will be held with staff regarding change in condition and implementation of TSP for all changes in condition. 2. All service plans will be reviewed for fall history. Interventions will be assessed for effectiveness. Service plan will reflect current effective interventions and historical non-effective interventions. Changes in condition will be monitored with TSPs and include a review of current and new interventions. The Wellness Director/RN will review all falls for follow up interventions. Frequent training/review with med/care staff regarding resident interventions and TSP process. TSP/Alert charting will be implemented for all changes of condition and reviewed multiple times per week for effectiveness of interventions. Service plans will be updated as determined by the Wellness Director/RN to reflect current effective interventions. 3. Daily, weekly, quarterly 4. Wellness Director/RN and Executive Director

Based on record review and interview, it was determined the facility failed to determine and document what action or intervention was needed for residents who had short-term changes of condition, communicated the actions or interventions to staff, monitored the interventions for effectiveness and documented weekly progress of the change until the condition resolved for 3 of 3 sampled residents (#s 6, 7 and 8) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in November 2021 with diagnoses including dementia.   A review of Resident 6's current service plan, temporary service plans, charting notes and interviews with staff were conducted during the survey. A review of the resident's record revealed s/he experienced the following short-term changes of condition: * New move-in 11/5/21; * Injury of unknown cause 11/5/21; * Non-injury fall 11/6/21; * New medication 11/13/21; and * New medication 11/15/21. There was no documented evidence the facility documented what action or intervention was needed, communicated the actions or interventions to staff and documented weekly progress of the change until the condition resolved. The need to ensure a system was in place to determine action or intervention needed for short-term changes of condition, communicate the interventions to staff and monitor the change of condition at least weekly until resolved was discussed with Staff 1 (Administrator), Staff 8 (Resident Services Director), and Staff 26 (RN) on 12/3/21. They acknowledged the findings. 2. Resident 7 was admitted to the facility in June 2021 with diagnoses of bipolar and anxiety. A review of Resident 7's current service plan, temporary service plans, charting notes and interviews with staff were conducted during the survey. Resident 7 experienced five falls between 10/31/21 and 12/1/21. The resident's 9/5/21 service plan and temporary service plans indicated s/he had a history of falls and instructed staff to perform three to four visual checks per shift, encourage to use call pendant, conduct frequent checks, keep walker within reach when in dinning room, and ordered a grabber to assist when picking up items from the floor. There was no documented evidence the facility thoroughly investigated the circumstances for each fall to determine if the service planned interventions were implemented and were effective, communicated new interventions to staff or monitored at least weekly through resolution after each subsequent fall. The need to ensure a system was in place to determine action or interventions needed after each subsequent fall, ensure the fall interventions were implemented and effective, communicated the fall interventions to staff and monitored the resident after each subsequent fall at least weekly until resolved was discussed with Staff 1 (Administrator), Staff 8 (Resident Services Director), and Staff 26 (RN) on 12/3/21. They acknowledged the findings. 3. Resident 8 was admitted to the facility in November 2021 with diagnoses including dementia.   A review of the resident's record revealed s/he experienced the following short-term change of condition: * 11/12/21, unwitnessed injury fall with skin tear to left knee and left elbow. There was no documented evidence the facility monitored the fall or skin tears with weekly progress until resolved. The need to ensure a system was in place to monitor changes of condition at least weekly until resolved was discussed with Staff 1 (Administrator), Staff 8 (resident Services Director), and Staff 26 (RN) on 12/3/21. They acknowledged the findings.

The identified records will be reviewed by MC Nurse with appropriate follow up and documentation that supports in evidence what action or intervention was needed, communicated the actions or interventions to staff and documented weekly progress of the change until the condtion resloved. The use and implemention of temporary service plans has been adressed to staff and nurses to determine action or intervention needed for short term changes to ensure these actions and or interventions are in place for staff to follow. Interventions or actions are documented with use of temporary service plans along with alert charting and updates to service plan as needed with a weekly nursing note until resolved with documentation to support if actions or intervention were effective. Med tech will take residents off alert and put tsp in nurses binder to prompt weekly nursing note for resolution. Ongoing appropriate use of temporary service plans to include direct clear communication for action or intevention for staff to implement\follow will be monitored weekly and at least quarterly in addtion to assessments and service plans as needed by MC nurse. MCD will assure compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for a significant change of condition, including findings, resident status and interventions made as a result of the assessment, for 2 of 3 sampled residents (#s 1 and 4) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in November 2020 with diagnosis of Vascular Dementia. Resident 4 was observed during the survey using a wheelchair for mobility and was a two person assist for standing and transfers. A progress note dated 7/10/2021 by Staff 5 (LPN) stated "...has sudden onset of change in condition with ambulation on 7/8/21 and currently a 1 to 2 person transfer assist and using a wheelchair for mobility with escort most of the time." On 7/27/21 Staff 10 (CG) reported that before the resident's condition declined he/she could stand and walk independently.  She stated that since the decline Resident 4 now required two person assist for transfers, used a wheelchair for all mobility, required full assist for all ADL cares and had increased incontinence of bladder. Staff 3 (RN) stated she had not completed an assessment for Resident 4's significant change of condition. The need to complete an RN assessment for significant changes of condition, to include findings, resident status and interventions, was discussed with Staff 1 (Administrator) and Staff 3 (RN). They acknowledged the findings. 2. Resident 1 was admitted to the facility in October 2018 with diagnoses including dementia. The resident's 4/25/21 through 7/25/21 progress notes and weight records from 1/2021 through 7/2021 were reviewed and the following was identified: * Resident 1 weighed 109.2 pounds on 6/3/21 and 100.8 pounds on 7/8/21. Resident 1 lost 8.4 pounds in one month, or 7.69% of his/her total body weight, which constituted a severe weight loss for one month. There was no documented evidence the RN completed a significant change of condition assessment. The need for a thorough RN assessment to be completed for all significant changes of condition was discussed with Staff 1 (Administrator) and Staff 2 (ED) on 7/28/21. They acknowledged the findings.

1. A significant change in condition assessment was completed and interventions added for Resident 4's service plan related to mobility status and ADL assistance/care needs. A significant change of condition assessment was completed and interventions added for Resident 1's service plan for weight change. Training will be done with RN specific to when and how to conduct a significant change of condition assessment including updated service plan. 2. All changes in resident condition will e reviewed by the Wellness Team to determine if it is a significant change of condition. All staff will be trained in how to recognize and respond to changes of condition including notifying RN or significant changes in condition. TSPs and alert charting will be reviewed multiple times per week by the Wellness Team to ensure identification and follow up of changes of condition. 3. Multiple times per week 4. Wellness Director /RN

2. Resident 3's July 1 through July 26, 2021 MAR was reviewed and identified the following: * Resident 3's MAR included two PRN bowel care medications: - Bisacodyl suppository every day as needed for constipation; and - Magnesium Citrate Lemon Liquid 30 ml every day as needed for constipation. * Resident 3's MAR included two PRN pain medications: - Acetaminophen every four hours as needed for pain; and - Tramadol HCL every six hours as needed for pain. The MAR lacked specific instructions for order of administration for the PRN bowel care and PRN pain medications. The need to ensure all medications on the MAR included specific instructions for administration was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 7/28/21.  They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included medication-specific instructions and parameters for the administration of PRN medications for 2 of 4 sampled residents (#s 2 and 3). Findings include, but are not limited to: Review of Residents 2's 7/1/21 through 7/25/21 MAR revealed the resident had multiple bowel, pain and nausea medications for each condition which lacked clear instruction to staff regarding the timing and sequence for administration of the medications. The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator) and Staff 2 (Executive Director). They acknowledged the findings.

1. Resident 2's MAR will be updated with clear instructions to staff regarding timing and sequency for bowel, pain and nausea PRN medications. Resident 3's MAR will be updated to include instructions for PRN Bisacodyl, Magnesium Citrate, Acetaminophen and Tramadol including. Med tech in-service will be scheduled to review following PRN parameters and notification of licensed nurse for missing parameters. 2. All orders will be reviewed using the three-check system. RN or MD will be notified for instructions for new PRN orders. Wellness Director or licensed nurse will review all PRNs for parameters when performing their third checks multiple times a week and reviewing quarterly Physician Orders. Missing parameters will be implemented by RN or LPN under the director of an RN. 3. Multiple times a week; quarterly 4. Wellness Director, licensed nurse

Based on interview and record review, it was determined the facility failed to ensure that 4 of 4 newly hired staff completed abdominal thrust and First Aid training within 30 days of hire. Findings include, but are not limited to: A review of staff training records on 7/28/21 revealed the following: There was no documented evidence Staff 5 (CG), hired 3/12/21, Staff 6 (CG), hired 6/29/21, Staff 18 (CG), hired 7/6/21, and Staff 22 (MT), hired 6/4/21, had completed the required training in abdominal thrust and First Aid. The need for staff to complete all required training within the appropriate time frame was discussed with Staff 1 (Administrator) and Staff 2 (ED) on 7/28/21. They acknowledged the findings.

1. All employee files will be reviewed for completed abdominal thrust and first aid training. All missing trainings will be assigned and completed. 2. New hire training schedule will be completed for all new hires to include first aid and abdominal thrust training within 30 days of hire. Training records will be reviewed 30 days after hired and quarterly for missing trainings. 3. 30-days after hired and quarterly 4. RSD, BOM, MCD

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to: A tour of the environment on 7/26/21 at 11:25 am revealed the following areas were in need of cleaning and/or repair: * Ceiling tiles throughout the north hallway were missing, exposing vents and wires; * Multiple light green chairs and loveseats on both the north and south units had dark stains; * Carpet from the central hallway to the dining areas on both north and south units had dark stains; * Two leather chairs on the south unit had rips in the fabric; * Numerous dining room chairs in both units had ripped upholstery on the seats; * Chipped paint and gouges were noted on the walls and baseboards in the north and south hallways, central hallway, laundry room and hopper room; * The coved floor in the laundry room was pulling away from the wall by the washer and door; * The base of the hopper had areas with a buildup of brown matter and the caulking had cracks and was not a cleanable surface; * The floors in the laundry and hopper rooms had an accumulation of black matter with increased density in corners and by the floor mats; * The floors in the central hallway by the north and south units had buildup of black matter by the doors; and * The nursing station desks on both units had gouges in the wood. The environment was toured with Staff 1 (Administrator) and Staff 7 (Plant Operations Director) on 7/26/21. The need to ensure the facility was maintained clean and in good repair was discussed. They acknowledged the findings.

1. The identified areas of concern with be cleaned or repaired: ceiling tiles are being replaced; green chairs will be cleaned or replaced; carpet in central hallway will be cleaned or replaced; ripped leather chairs will be removed; ripped dining chairs will be repaired or replaced; chipped paint/gouges will be painted in hallways, laundry and hopper rooms; laundry/hopper room flooring will be cleaned, repaired or replaced; caulking at base of hopped will be removed and redone; hallways flooring will be cleaned to remove black mater; nursing station desks will be repaired or replaced. In-service/training with all staff to review process for reporting environmental cleaning/maintenance needs. 2. POD or designee will do weekly walk through of interior and exterior of the community to ensure the building is maintained, clean and in good repair. All items needing cleaning/maintenance will be reported to front desk. Front desk will put in all work orders. When reception at front desk is not available, manager on duty will email reception and POD with maintenance request.   POD and management will quarterly review that all work orders are either completed or being addressed timely. 3. Daily, Weekly, Quarterly 4. POD, ED

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to: A tour of the environment on 12/1/21 identified the following areas were in need of cleaning and/or repair: * Ceiling tiles throughout the north hallway were missing, exposing vents and wires; * Multiple light green chairs on the north unit had dark stains; * Carpet from the central hallway to the dining areas on south unit had multiple dark stains; * Numerous dining room chairs in both units had ripped upholstery on the seats; and * The nursing station desks on both units had gouges in the wood. The environment was toured with Staff 1 (Administrator) and Staff 7 (Plant Operations Director) on 12/2/21. The need to ensure the facility was maintained clean and in good repair was discussed. They acknowledged the findings.

The area of concerns has been or will be adressed by 1\30\2022 With exception of dinning room chairs i have sent documenatation over to CBC with contents of a plan in place with a desinger team, to ensure chairs will be reupholstered. Ceiling tiles\exposed wires will be put back into place, green chairs have been removed with new chairs in place. Carpets have been professionaly cleaned, the nursing station desk will be fixed\repaired to repair gouges in the wood, Maintenance and all staff will receive additional training on the requirements for reporting items that need repair in addition to identified areas of concerns.The reported concerns will be notified to maintenance through a tels notification system. Professional carpet cleaning will be scheduled on an ongoing basis and as needed to ensure up keep on carpets. Management team will do weekly walk through of interior and exterior of the grounds to ensure bulding is maintained clean and in good repair, findings will be reported in Tels system to prompt plant operations director to follow up on reported findings. MCD and ED will assure compliance.

Based on observation and interview, the facility failed to ensure the hot water temperature in residents' units was maintained within a range of 110 - 120 degrees Fahrenheit. Findings include, but are not limited to: During a tour of the environment on 7/26/21 at 11:25 am, the north unit was observed not to have hot water in resident rooms, the unit kitchen and the common area bathroom. In an interview with Staff 7 (Plant Operations Director) on 7/26/21 at 12:30 pm, he reported that three of the five water heaters that supply hot water to the facility stopped working on 7/14/21. He reported that the units on the north side of the building were without hot water and were temporarily using the showers in the pool locker rooms and in vacant resident apartments on the south side of the building. Additionally, he stated that the hot water supply to the remainder of the facility was limited. Staff 7 reported that the facility was waiting on corporate approval of bids to proceed with the work.  A timeline for the repairs was requested and was provided in writing at 2 pm on 7/26/21. The facility anticipated that one hot water heater, which would supply hot water to the northern unit in limited supply, would be installed within 10 days, and that delivery and installation of the final two hot water heaters could take three to six weeks. The need to ensure the facility hot water in resident rooms was maintained within a range of 110-120 degrees Fahrenheit was discussed with Staff 1 (Administrator) and Staff 7 on 7/26/21. They acknowledged the findings.

1. The north wing's hot water heater has been installed on 8/6/2021 all hot water heaters are installed and in proper working order. Currently the north wing and the rest of the building have hot water. 2. POD will check hot water temperatures weekly to ensure range within 110-120 degrees Fahrenheit. POD will document temperatures. Items needing maintenance will be reported to front desk who completes work order. POD to follow up timely on items needing repair. POD will complete weekly walk-throughs of community to ensure equipment is in good working order and evaluated for repair or replacement. POD will review work orders multiple times a week and quarterly for completion. 3. Daily, Weekly, Quarterly 4. POD, ED

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231, C372, C513 and C545.

Refer to POC C 231, C372  C310

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

Refer to POC C 513

Based on interview and record review, it was determined the facility failed to ensure 1 of 4 newly hired staff completed all required pre-service orientation prior to beginning job duties and demonstrated competency in their job duties within 30 days of hire, and 4 of 4 long term staff completed the required number of hours of annual training. Findings include, but are not limited to: Staff training records were reviewed on 7/28/21. a. Training records for Staff 5 (CG), hired 3/12/21, lacked documented evidence the following pre-service orientation elements were completed: * Resident rights and values of CBC care; * Abuse reporting requirements; * Standard precautions for infection control; and * Fire safety and emergency procedures. b. Training records for Staff 5 (CG), hired 3/12/21, and Staff 23 (MT), hired 6/4/21, lacked documentation that competency in their job duties was demonstrated within 30 days of hire. c. Training records for Staff 14 (MT), hired 6/13/19, Staff 16 (CG), hired 7/7/20, Staff 21 (MT), hired 6/13/19, and Staff 25 (CG), hired 8/27/19, lacked documentation of completion of 10 hours of training related to the provision of care in CBC and 6 hours of training related to dementia care annually. The need to ensure all required training was completed within the specified time frames was discussed with Staff 1 (Administrator) and Staff 2 (ED) on 7/28/21. They acknowledged the findings.

1. All staff training records will be reviewed for pre-service orientation and demonstrated competency. All missing training will be assigned and completed including resident rights and values; abuse reporting requirements; standard precautions for infection control; fire safety and emergency procedures; 6 hours of preservice dementia training. 2. All new hires will complete pre-service orientation and demonstrate competency in their job duties prior to performing job duties. Pre-service orientation checklist will be implemented and reviewed for completion prior to new hire performing job duties by BOM. All new hire training will be reviewed quarterly for completion. 3. Prior to new hire starting duties and quarterly 4. BOM, MCD

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, C280 and C310.

Refer to POC  C 260 C 270 C280

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

Refer to POC C 270

Based on interview, observation and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans, or were followed for 1 of 4 sampled residents (# 1) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 10/2018 with diagnoses including dementia. During survey, Resident 1 was observed to require cueing and feeding for meals. Resident 1's current service plan, dated 6/16/21, was reviewed. The service plan lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator) and Staff 2 (ED) on 7/28/21. They acknowledged the findings.

1. Resident 1 will be assessed for cuing and feeding needs. Service Plan will be updated to reflect her feeding needs. Current: Give resident small portions, as large portions are overwhelming. Caregiver to serve this resident towards the end of mealtimes as there is less distraction. Caregiver to sit with resident encourage\cue resident to eat,.(ie) pick up fork, take a bite. If resident is not feeding herself then caregiver is to assists with feeding needs.  Care staff in-serviced on importance of proper nutrition and hydration for resident, reviewing service plans for how to individualize for each resident and CLG policies on nutrition and hydration. 2. All resident files will be reviewed to ensure individualized hydration and nutrition plan and staff instructions are present. All new move-ins will be evaluated for individualized nutrition and hydration plan. Service Plan will be updated upon move-in and as determined by wellness director or RN. 3. Move-in and quarterly and significant changes. 4. Wellness Director or Licensed nurse

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation for 2 of 4 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to: Though Resident 1 and 2's service plans offered some information about the resident's interests, the facility had not fully evaluated the residents': * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Director) on 7/28/21. They acknowledged the findings.

1 and 2's service plans were reviewed and updated to include individualized activity plans including current abilities an skills; emotional and social needs and patterns; physical abilities and limitations; adaptations necessary for the resident to participate and activities that could be used as behavioral interventions if needed. Resident 1's service plan included:  Resident will need escort to activities as she is not able to take herself. Staff to bring resident to common areas daily so that she is not isolated in her room. Resident enjoys being around other people, this brings her comfort. She is a fall risk, having her in common areas helps staff keep eyes on her.    Resident enjoys all music. Staff to escort resident to music activities. She is able to participate in other activities, with help from staff, staff to assist with the fundamentals of setting up and participating in daily activities, (IE) coloring, place paper and color pencils in front of resident, bingo, place card and markers in front of resident and cue and assist when numbers are called. Resident might not participate due to cognitive decline, she enjoys being around others and this is stimulation to her. Having resident around others also helps with her anxiety. If situations are to overwhelming, (ie) resident fidgeting in her chair, trying to get up on her own, bending over to pick things off floor, having a distressed look on her face, grimacing, remove resident from over stimulating areas and have her in a quiet area. Service plan updates to also to include staff direction for resident specific activities like frequency. All staff in-service will be schedule to review company memory care training "Meaningful days and dealing with challenging behaviors." In-service will also review staff role in facilitating/participating in activities.   2. Resident's service plans will be reviewed quarterly by LED, WD, or LN for current activity plan or modifications needed. 3. Quarterly 4. LED, WD or LN

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation for 2 of 2 sampled residents (#s 6 and 8 ) whose records were reviewed. Findings include, but are not limited to: Resident 6 and 8's individualized activity service plans had not fully evaluated the residents': * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. The need to ensure each resident was evaluated and had an individualized activity plan was reviewed with Staff 1 (Administrator) and Staff 27 (Activities Director) on 12/3/21. They acknowledged the findings.

The identified records will be reviewed and revised on or before 1/17/22 records will be update for residents individualized activity service plan and activity evaluation to include detailed what, when and how and how often staff should offer and assist the residents with more individualized activities.Residents will receive all appropriate recreational activities reflected in service plan with current\past likes\dislikes, with person centered specific individualized plan to reflect current ablilities and skill , emotional and social patterns, physical abilities and limiations, adaptions necessary to participate. Caregivers and Activities department will be retrained on service plan and meaningful person centered directed activity plans along with additional training on following the sevice plan for individualized activity plans and on going. Activities Director will update Activity section in service plan to reflect current idividualized activites and their requirements. This system will be evaluated quaterly and in addtion to Change of condtion and assessments to reflect current person centered individualized activity plan By MC Nurse and Activities Director. MCD will assure compliance.

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 1 sampled resident (#3) with documented behaviors. Findings include, but are not limited to: Resident 3 was admitted to the facility in July 2016 with diagnoses including advanced dementia and acute anxiety. Resident 3's record documented behaviors including yelling, hitting out at staff and residents and wandering into other resident's rooms which resulted in a resident to resident altercation on 5/10/21. The resident's service plan, dated 7/4/21, did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 7/27/21 and 7/28/21 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Administrator), Staff 3 (RN), Staff 4 (LPN) and Staff 5 (LPN). The staff acknowledged the findings.

1 Resident 3's behaviors will be reviewed and service plan updated with effective interventions.Memory Care Nurses will do behavioral assessment and provide a behavioral plan for direct care staff to ensure resident specific interventions for the management of behaviors are included on the identified service plan.All staff in service will be scheduled to review "meaningful days and dealing with challenging behaviors" and discuss speccific residents behaviors and effective interventions. 2 Resident specific interventions for the management of behaviors are included on all other service plans with identified behaviors. Memory CareLPNs to ensure the behavior plan will be monitored until a pattern of intervention effectiveness is achieved. The behavioral plan will then be reviewed and evaluated in accordance to service plan review which is within 30 days of move in, quarterly, or with a significant changes. For implementation or modifications of behavioral plans. 3  Move in, 30 day, 90 and significant changes. 4 Wellness Director, Licensed Nurse and MCD

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 C270,C 513, Z 142, Z 162, and Z 164

Refer to POC C 513, C 270

The findings of the change of ownership relicensure survey conducted 7/26/21 through 7/28/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit survey to the change of ownership relicensure survey of 7/28/21, conducted 12/1/21 through 12/3/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second revisit to the re-licensure survey of 07/28/21, conducted 03/15/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.