The Arbor at Avamere Court

Based on observations, interviews, and record review, it was determined the facility failed to follow texture components of diet orders for 1 of 1 randomly selected resident (# 1) needing puree diet textures. The incorrect diet texture placed the resident at risk for aspiration and/or choking. Findings include, but are not limited to:

Resident 1 had a current physician order dated 06/17/25 noting the following diet order: “Regular diet: Pureed Texture, IDDSI [International Dysphagia Diet Standardization Initiative] Moderately Thick consistency.”

On 09/05/25 at approximately 11:30 am Resident 1 was observed to be given her meal. Shortly after taking the first bite resident was observed to start coughing. Care staff did respond and go to resident asking if they were ok. The resident did nod indicating they were “OK”. Resident took another bite and began coughing again. Staff intervened and offered the resident a drink of their thickened liquid which appeared to subside the cough. After a few minutes passed the resident took another bite and again began coughing. The surveyor went over to view the resident’s meal and the meal texture did not look smooth as was expected with appropriate texture.

Surveyor went to the North Unit and observed a plated meal designated as puree that had yet to be given/served to a resident. Upon investigation of the food products revealed several big chunks of whole unprocessed pieces of vegetables (carrots and green beans) or meat and the overall texture was not smooth as needed/necessary for appropriately pureed textures. Surveyor instructed Staff 4 (Cook) the items as plated could not be served. Staff 4 acknowledged the whole chunks were not appropriate for puree textures and they would serve any remaining residents needing puree something else. Staff 4 acknowledged that all puree items were mechanicalized together in batches and then individual resident servings taken out of the batches confirming the observed texture of the meal for resident 1 was not appropriate.

At approximately 12:20 pm, surveyor presented the incorrectly pureed food items to Staff 1 (Administrator) who acknowledged the unsmooth and larger pieces in the pureed items that would not be appropriate for a resident needing pureed textures. Staff 1 acknowledged the presented texture would be a potential safety issue for residents needing puree diet. Surveyor informed Staff 1 of the observation of Resident 1 difficulty with lunch meal and the multiple coughing episodes. Staff 1 verbalized understanding and acknowledged the lunch meal presented appeared to not be the correct and safe texture for residents needing puree.

At approximately 1:00 pm, Surveyor interviewed both cooks on duty (Staff 4 and 5). Both cooks acknowledged the larger pieces observed in lunch for puree was not appropriate or safe for residents needing puree texture. Surveyor asked staff to demonstrate appropriate pureed food items and neither cook understood the appropriate level of smooth texture needed for puree textures. After demonstration by surveyor Staff 4 and 5 were then able to understand and demonstrate the correct level of mechanicalizing of food items to produce a smooth/appropriate puree textures.

On 9/08/25 surveyor returned to facility for lunch meal preparation and service and validated puree textures were correct. Resident 1 was observed during lunch meal and was not observed to cough throughout the lunch observation.

On 09/08/25 at 12:28 Staff 2 (Dining Services Director) was interviewed and acknowledged the facility had not been pureeing items correctly.

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 North and South unit kitchenettes on 09/05/25 from 10:40 am through 2:00 pm and again on 09/08/25 from 10:00 am through 2:00 pm revealed the following:

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:

* Walls, and flooring behind/underneath of the dish machine;
* Industrial mixer;
* Industrial slicer;
* Large can opener and housing;
* Black tray holding clean dishes above service line;
* Large can metal storage rack;
* Speed rack in walk in cooler;
* Metal rack in walk in freezer;
* Interior of white bulk food storage container;
* Top of dish machine;
* Top of specialty coffee/cocoa machine;
* Drain under dish machine; and
* Juice machines in unit kitchenettes.

b. The following areas needed repair:

* Metal racks in walk in cooler had rust accumulation;

c. Salad dressing containers in both units not dated with dates opened or use by dates. Salad dressing containers in deli cooler in main kitchen did not have open or use by dates. Multiple items noted in deli cooler without open dates.

d. Multiple food items found past manufactures use by dates. Container of peperoni was observed well past use by date and visible signs of molding/spoilage were observed.

e. Two large boxes of sprinkles found stored open to potential contamination. Ice cream bars in North unit freezer observed stored unwrapped/open to potential contamination. Containers of single use disposable utensils/service ware were stored open exposing items to potential contamination.

f. Room trays for residents were observed on both units to be delivered/transported to the rooms without food or beverages covered/protected from potential contamination.

g. A large soup kettle pot was observed stored in the walk-in cooler full of soup made the evening before. Staff were interviewed about proper cooling methods and time temperature guidelines to ensure safety. Staff were not able to discuss proper ways to cool items nor able to discuss temperature levels and time frames needed for safe storage. Staff verified the soup did not undergo any further steps to ensure safe storage. Staff 2 (Dietary Manager) was interviewed on 09/08/25 at 12:38 pm and acknowledged staff did not follow appropriate cooling steps and would discard the soup.

h. The evening meal cook was not able to correctly state proper cook to temperatures for chicken/poultry. Menus were reviewed and multiple meals included chicken as a main entrée.

i. Multiple bulk food items were found with scoops/utensils stored with hand contact areas touching food surfaces potentially contaminating the food product.

j. White cutting boards were found heavily stained and scored and in need of replacement. Multiple fry pans observed with integrity issues. Multiple North unit resident reusable straws were found heavily stained and in need of replacement.

k. Facility did not have the correct test strips to test/validate the surface sanitizer and three compartment sink sanitizer. Kitchen staff were not aware of the chemical used for sanitation and were not able to state the appropriate parts per million (PPM) needed for sanitation. Surveyor was able to validate sanitizer dispenser was dispensing correct concentration of sanitizer with surveyor provided strips. The incorrect chemical was posted on the dispenser.

l. Kitchen staff did not have appropriate knowledge of puree diets to ensure diets were served as ordered. Puree food items for lunch on 09/05/25 were observed with visible chunks and/or large whole pieces of food mixed into the more mechanicalized pieces. There was no smooth blended texture observed to the food items. On 09/08/25 at 12:38 pm, Staff 2 was interviewed and acknowledged the facility was “doing puree wrong.” Staff 2 acknowledged they had not had any official training on puree textures.

m. On both days of survey lunch meal was prepared and in ovens/warmers well before lunch service. On 09/05/25 lunch was in ovens/warmers at 10:40, at least one hour before service. On 09/08/25 lunch meal items were observed complete and in oven/warmers at 10:00am over 1 hr 30 minutes prior to meal service times. Staff 2 was interviewed regarding the possible reasons why meal items were cooked that far in advance of meal service times, and they indicated the staff have just done that since he started. Staff 2 was asked the barriers to preparing food closer to meal service times and he said there weren’t any. Staff 2 acknowledged cooking that far in advance with extended hot holding could continue to cook food and lead to potential food quality concerns/outcomes.

On 09/08/25 at approximately 12:30 pm, Staff 2 was informed of above areas and acknowledged the needed correction. At 1:30 pm, the surveyor reviewed with Staff 1 (Administrator) the noted areas and they were acknowledged.

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

Refer to C240.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (#4) who had documented medication refusals. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2023 with diagnoses including dementia.

A review of the resident's physician orders and 10/01/24 through 10/21/24 MAR identified the resident had refused multiple medication and treatments on 66 occasions.

There was no documented evidence the physician had been notified of the refusals, or a signed order stating how often the physician would like to be notified of refusals.

On 10/24/24, the need to ensure the facility notified physicians of medication refusals was discussed with Staff 1 (ED) and Staff 2 (Director of Health Services). They acknowledged the findings.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse

(j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to:

The exterior of the facility was toured on 10/21/24. Exterior pathways in MCC courtyards contained multiple drop offs up to two inches, measured from the concrete to the ground. These drop-offs created potential fall hazards for residents.

On 10/22/24, the building's exterior was toured with Staff 1 (ED) and Staff 6 (Plant Operations Director). They acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior

(3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the facility was clean, in good repair, and free of unpleasant odors. Findings include, but are not limited to:

Observations of the Northside and Southside MCC units from 10/21/24 through 10/24/24 identified multiple walls, door frames, and window frames with chipped and missing paint in common areas.

On 10/22/24, the areas in need of repair were toured with Staff 1 (ED) and Staff 6 (Plant Operations Director). They acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the facility was clean, in good repair, and free of unpleasant odors. Findings include, but are not limited to:

Observations of the Northside and Southside MCC units from 10/21/24 through 10/24/24 identified multiple walls, door frames, and window frames with chipped and missing paint in common areas.

On 10/22/24, the areas in need of repair were toured with Staff 1 (ED) and Staff 6 (Plant Operations Director). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to information being accessible in common areas of the facility for 2 of 4 sampled residents (#s 2 and 3) and 2 unsampled residents. Findings include, but are not limited to:

During the survey, 10/21/24 through 10/24/24, four resident room doors were observed to have notes attached which contained resident-specific information including their personal preferences and/or medical health information. The door notes were accessible for public viewing, which jeopardized the residents’ rights to privacy and dignity.

The need to ensure resident privacy and dignity was reviewed with Staff 1 (ED) and Staff 2 (Director of Health Services) on 10/24/24. They acknowledged the findings.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity

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

This Rule is not met as evidenced by:

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

Refer to C510 and C513.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

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 C305.

OAR 411-057-0160(2b) Compliance with Rules Health Care

(b) Health care services provided in accordance with the licensing rules of the facility.

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to evaluate the resident for activities and develop an individualized activity plan based on their activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to:

Residents 1, 2, 3 and 4 resided in the Memory Care Community and were diagnosed with dementia. Each resident was observed needing various degrees of assistance to initiate and participate in activities.

Resident 1 was observed self-propelling around the unit in a wheelchair. The resident observed several activities but did not actively participate. Resident 2 was recently admitted to the facility. Resident 2 was able to ambulate independently and spent most of the day in his/her room watching TV. Resident 3’s condition had recently declined leaving him/her bedbound, needing increased assistance with many ADLs and sleeping a lot during the day. No activities were observed to be offered to the resident during the survey. Resident 4 was recovering from a recently diagnosed urinary tract infection which contributed to increased confusion and aggressive behaviors toward staff. During the survey, the resident was observed sleeping on couches or in other common areas and did not participate in activities.

Resident 1, 2, 3 and 4's service plans were reviewed. Though the activity section of the service plan offered some information about the residents’ past and current interests, information about one or more of the following areas was lacking:

* Current abilities and skills;
* Emotional and social needs and patterns;
* Physical abilities and limitations;
* Adaptations necessary for participation; and
* Activities that could be used as behavioral interventions.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities.

The need to develop individualized activity plans which were based on a thorough assessment of the residents’ interests, abilities and needs was discussed with Staff 1 (ED) and Staff 2 (Director of Health Services) on 10/24/24. They acknowledged the findings and reported they were already implementing new processes to improve all residents’ activity plans.

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.

This Rule is not met as evidenced by:

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

Observation of the main facility kitchen and the North and South unit kitchenettes on 10/15/24 from 11:00 am thru 1:15 pm and 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:

* Pipes, walls, and flooring behind/underneath of the dish machine;
* Ceiling vents;
* Industrial mixer;
* Industrial slicer;
* Large can opener and housing;
* Reach in deli cooler;
* Tray holding clean dishes;
* Interior of ice scoop holder;
* Interior of ice machine
* Interior of both unit kitchen ovens;

b. The following areas needed repair:

* Caulking in ware washing area with black matter debris buildup;
* Large accumulation of water under dishwasher and in dishwashing area.
* Large scale build up in dishwasher.
* Industrial dishwasher was not washing at 150 degrees Fahrenheit as required.
* Steamer out of service due to scale build up.
* Water damage to areas behind sinks in both North and South units.
* Plug in to hot cart in North unit not working and unable to plug in to keep items warm when delivered to units.

c. Multiple food items/packages/containers found in reach in deli cooler that were not dated when opened/prepared. Salad dressing containers in both units not dated with dates opened or use by dates.

d. Multiple cooking pans and were found in poor repair (heavy carbon/grease build up and/or non stick coating with scratches) and were in need of replacement.

e. Large bag of oats found in dry storage open and exposed to potential contamination. Large boxes of single use disposable utensils were stored open exposing utensils to potential contamination.

f. Multiple open fly/insect trap paper strips were located throughout the kitchen area with multiple visible dead insect carcasses attached hanging above areas with clean dishes and food transport areas.

g. Multiple care staff assisting residents to eat did not have a protective barrier/aprons on to help prevent potential contamination from care tasks to meal/dining tasks. 2 care staff in South unit observed handling either an iPad or pager then proceed to assist residents with meals and/or getting drinks including handling straws without a hand hygiene step.

h. Care staff was observed in both units to transport resident meals/desserts or beverages without being covered/protected from potential contamination.

i. Per interview with staff 2 (Director of Food Service) at approximately 12:30 pm, residents receiving pureed textures where not served the current days menu items. All purred meals were from previous days menu items. Staff 2 acknowledged this practice was not due to resident choices or wishes to have the previous days menu items and was for facility convenience. Staff 2 stated they were unaware that was not an acceptable practice. Staff 2 stated they would begin pureeing foods for residents with that texture according to what was on the posted menu for all residents, unless it was at the specific request of the resident as per their right. At this time, surveyor reviewed the above identified areas in need of correction with staff 2. Staff 2 acknowledged the areas.

At 1:00 pm, Staff 1 (Business Office manager) was informed of the concerns found and they acknowledged the need for correction.

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

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

This Rule is not met as evidenced by:

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

Refer to C240.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

The findings of the on-site investigation, conducted on 06/15/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a dayNotes on Abbreviations: " The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. " Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate." Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. " If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on interview and record review, conducted during a site visit on 06/15/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, for 1 of 1 sampled (#1). Findings include, but not limited to: On 02/23/23, Witness 1 stated in the complaint, on 12/04/22 around 9:00 pm the pull cord in Resident 1's bathroom was pulled, no one came for almost 45 minutes.In an interview on 06/15/23, Staff 1 stated the expectation for call light response time was less than15 minutes. A review of Resident 1's call history on 12/04/22, indicated at 8:55 pm the call light went off in Resident 1's room and went unanswered for 46 minutes. An additional review of Resident 1 call history between 11/03/22-11/05/22, indicated 10 occurrences where the call light exceeded the 15-minute response time. Four times where the call light was not answered for over an hour. It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each residentOn 06/15/23, the findings were reviewed with and acknowledged by Staff 1(Executive Director). Verbal plan of correction: Staff 1 stated that this occurrence happened back in December 2022 and the call lights have improved since then.

Based on interview and record review, conducted during a site visit on 06/15/23, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to:On 06/15/23, the facility's ABST was reviewed, and the staffing levels generated indicated the facility required nine care staff on day shift, seven care staff on swing shift, and two care staff on night shift. There were 14 residents' profiles that had not been updated quarterly. A review of the posted staffing plan indicated for day and swing shift there are to be four CG and one MT scheduled and on NOC shift there are to be two CG and one MT. In an interview on 06/15/23, Staff 1 (Executive Director) stated the facility is using the ODHS ABST. S/He was unable to demonstrate how the hours were calculated to determine the facility's staffing levels. The facility is home to 45 residents. Staff 1 explained there are two wings of the building and on day and swing shift there are two CG on each wing and one shared MT. On NOC shift there are two CG with one on each wing and one shared MT. Staff 1 stated s/he does not know how to convert their staffing levels using the acuity-based staffing tool and the facility is staffing to what their corporate office tells them they are budgeted for. The facility failed to implement and update an acuity-based staffing tool. On 06/15/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: CS showed Staff 1 how to calculate hours needed based on the ABST tool. Staff 1 will reach out to OPA and CAC for ABST to further understand the tool within the month.

The findings of the relicensure survey conducted 10/18/21 through 10/20/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 10/21/21, conducted 01/19/22 through 01/20/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit to the re-licensure survey of 10/21/21, conducted on 03/14/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the 3rd revisit to the re-licensure survey of 10/20/21, conducted 05/09/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 3) and failed to complete quarterly evaluations for 1 of 1 sampled resident (# 4), whose records were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 07/2021. Resident 3's move-in evaluation failed to address the following required elements:* Mental health issues, including history of treatment and effective non-drug interventions;* Personality, including how the person copes with change or challenging situations;* Activities of daily living, to include personal hygiene and ambulation; * Nutrition habits, fluid preferences and weight if indicated; and* Environment factors that impact the resident's behavior including, but not limited to lighting, room temperature. The facilities failure to complete all required elements for Resident 3's new move -in evaluation was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 04/2020.The evaluation available to the staff and survey team during the survey was last reviewed and updated on 04/20/21.On 10/20/21, the need to ensure that the facility performed evaluations at least quarterly, to correspond with the quarterly service plan updates was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 7) whose move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 7 was admitted to the facility in 12/2021. Resident 7's move-in evaluation failed to address the following required elements:* Spiritual and cultural preferences;* Customary routines, hobbies, social and leisure activities;* Personality, including how the person copes with change or challenging situations;* Cognition, including memory and confusion;* Activities of daily living, to include personal hygiene and ambulation; * Nutrition habits, fluid preferences and weight if indicated; and* Environment factors that impact the resident's behavior including, but not limited to lighting, room temperature. The need to ensure new move-in evaluations addressed all required elements was discussed with Staff 3 (Regional Director of Operations) and Staff 17 (RCC) on 1/20/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services, for 2 of 4 sampled residents (#s 1 and 3), whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 02/2019 with diagnoses including dementia. Observations of Resident 1, his/her apartment and interviews with staff were conducted throughout the survey. The resident's 10/12/21 service plan and 07/22/21 through 10/18/21 facility Progress notes were reviewed.The resident's current service plan was not reflective and did not include clear instruction for staff in the following areas:* The resident no longer used a transfer pole;* A two-person transfer;* The use of bilateral side rails;* Four-wheel walker was no longer used; and * The diet changed from regular to mechanical soft.The need to ensure service plans were reflective of the resident's current health status and provided clear instruction to staff was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director), and Staff 3 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 07/2021 with diagnoses of dementia, anxiety, hallucinations and was identified as an elopement risk.Observations of Resident 3 during the survey, interviews with staff and review of the service plan, progress notes and general records revealed the service plan was not reflective in the following areas: * How often safety checks were to be performed for elopement risk;* Hallucinations and anxiety lacked description of behaviors and interventions/instructions for staff;* Fall history and interventions;* Finger nail and foot care instructions; and* Dietary preferences.The need to ensure service plans were reflective and provided clear instructions to staff was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2, 3 and 4's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of the service plans.The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated and monitored to resolution, and failed to determine and document actions or interventions and communicate those to staff for 1 of 4 sampled residents (# 3) who experienced changes of condition. Findings include, but are not limited to: Resident 3 was admitted to the facility in 07/2021 with a diagnoses of dementia, anxiety and hallucinations. Resident 3's record was reviewed during the survey and the following was revealed:* 08/03/21 Resident 3 reported fear, thinking another resident was going to hurt him/her; and* 09/13/21 Resident 3 had a fall resulting in an eye contusion and left hip and arm pain. There was no documented evidence the facility evaluated, put interventions in place and/or monitored the above changes of condition to resolution. The need to ensure short-term changes of condition were evaluated, interventions developed and changes of condition were monitored through resolution was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 1 of 1 sampled resident (# 1) who experienced a significant change of condition. Findings include, but are not limited to:Resident 1 was admitted to the facility in 02/2019 with diagnoses including dementia. During interviews on 10/18/21 with Staff 2 (MT/Life Enrichment Director) and Staff 15 (MT), Resident 1 was identified to have had a decline resulting in a hospitalization and subsequent admission to hospice care. In interviews on 10/19/21 with Staff 13 (MT) and Staff 15, the resident was identified to have gone from a one-person transfer using a transfer pole to a two-person Hoyer lift transfer and from ambulating with a walker to using a wheelchair. The resident also declined in ability to eat a regular texture diet to needing a mechanical soft diet and was now receiving hospice services. Progress notes dated 07/22/21 through 10/18/21, and interviews with care staff on 10/18/21 through 10/20/21 showed the resident had an overall decline as follows: * On 8/19/21 a progress note identified the resident went from being a one-person transfer to a two-person transfer using a Hoyer lift.* A progress note dated 8/20/21 identified the resident had been sent out to the hospital related to "signs of nausea and vomiting" and "uncontrollable shaking."* Staff 15 (MT) wrote a progress note on 08/22/21 that the resident may be returning to the facility on hospice services and another note on 08/24/21 noted the resident had been hospitalized for sepsis.* On 8/27/21 a progress note and ISP (Interim Service Plan) identified the resident had returned to the facility with a catheter, new pain medication, discontinuation of some of his/her medications, fluid enhancement and staff were to do frequent checks.* Further progress notes included staff monitoring of the resident for the return from the hospital and additional medication changes. On 8/7/21 Staff 16 (RN) wrote a brief progress note which indicated the resident had returned to the facility, but was unable to start on hospice services until 08/03/21. There was no assessment of Resident 1's change of condition, interventions determined and no updated to the service plan.The facility failed to ensure an RN assessment was completed related to the resident's decline and the hospice admission which documented findings, resident status and interventions made as a result of the assessment. The need to ensure an RN assessment was completed for significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 06/2020 with diagnoses including Alzheimer's disease. Resident 2's signed physician orders and 10/01/21 through 10/18/21 MAR were reviewed. The following was identified:The resident had been receiving Mirtazapine (antidepressant) 15 mg one time daily. Review of the resident record revealed there was no signed order. At the request of the surveyor, the facility obtained a copy of the order on 10/20/21 to put in the record.On 10/20/21, the need to ensure singed physician orders were in the resident record was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 3 (Regional Director of Operations). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure signed physician's orders were in place for all medications administered to the residents for 3 of 4 sampled residents (#s 2, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 07/2021 with diagnoses including dementia, hypertension and angina (chest pain). The resident's 10/01/21 through 10/18/21 MARs and physician's orders were reviewed. The following medications had no documented evidence of a physician's order in the resident's medical chart: * Amlodipine (for hypertension);* Calcium Carbonate Antacid (supplement);* Centrum Silver Multivitamin-Minerals;* Cholecalciferol (supplement);* Culturelle (for digestive health);* Isosorbide Mononitrate ER (for angina);* Losartan Potassium ( for hypertension);* Pravastatin (for chloresterol);* Famitodine (antacid);* Metoprolol Tartrate (for hypertension);* Potassium Chloride (for low potassium);* Ranolazine ER (for chronic angina);* Albuterol inhaler PRN (for congestive obstructive pulmonary disease);* Nitroglycerin PRN (for angina); and* Zofran PRN (for nausea/vomiting).At the request of the surveyor, the facility obtained a copy of the order on 10/19/21 to put in the record.The need to ensure signed physician's orders were in place for all medications administered was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings. 2. Resident 4 was admitted to the facility 04/2020 with diagnoses including dementia and diabetes and received insulin injections daily. The resident's 10/01/21 through 10/18/21 MARs and physician's orders were reviewed.The following medications had no documented evidence of a physician's order in the resident's medical chart: * Discontinuation of Novolog Insulin, ordered to be administered in the pm daily; and* Insulin Aspart sliding scale, administered before dinner daily based on the resident's blood glucose levels.The need to ensure signed physician's orders were in place for all medications administered was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 02/2019 with diagnoses including dementia. Resident 1's signed physician orders and 10/01/21 through 10/18/21 MAR were reviewed. The following deficiency was identified:Resident 1 had a physician's order for Lorazepam (sedative) 0.5 mg every two hours and needed for anxiety. There was no information for staff how the resident exhibited signs and symptoms of anxiety, or what non-pharmacological interventions were to be attempted prior to administering the psychotropic medication.The need to attempt non-drug interventions prior to administering PRN psychotropic medications was reviewed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 3 (Regional Director of Operations). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behaviors and anxiety had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 2 of 2 sampled residents (#s 1 and 3) who were prescribed PRN medication to address behaviors. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 07/2021 with diagnoses including dementia, hallucinations and anxiety.Review of the resident's 10/01/21 through 10/18/21 MAR and 09/01/21 physician order showed the following psychotropic medication:* Quetiapine 25 mg (a psychotropic medication) one tablet a day as needed for agitation.The facility administered the Quetiapine on three occasions between 10/01/21 and 10/18/21.The MAR stated the medication was for "behaviors" and did not contain resident specific parameters for staff describing what behaviors or how the resident expressed the behaviors. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medications. The need to ensure there were resident-specific descriptions of the behaviors for administration of a PRN psychotropic medication, how the resident expressed the behavior and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/2021. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed for assistive devices with potentially restraining qualities for 1 of 1 sampled resident (# 1) reviewed who had a supportive device. Findings include, but are not limited to:Resident 1 was admitted to the facility in 02/2019 with diagnoses including dementia.During the entrance conference on 10/18/21, Resident 1 was identified as having bilateral side rails on his/her bed. Observations of the resident and the residents room showed the side rails were on the bed. Review of Resident 1's record revealed there was no documented evidence an assessment of the side rails had been completed by an RN, PT or OT nor were the devices with restraining qualities included on the resident's service plan. The lack of assessment and service planning for devices with restraining qualities was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 3 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed for assistive devices with potentially restraining qualities for 1 of 1 sampled resident (# 5) who had a supportive device. This is a repeat citation. Findings include, but are not limited to:Resident 5 was admitted to the facility in 11/2014 with diagnoses including dementia.During the entrance conference on 01/19/22, Resident 5 was identified as having bilateral siderails on his/her bed. Observations of the resident and the resident's room showed the siderails were on the bed. Review of Resident 5's record revealed there was no documented evidence an assessment of the siderails had been completed by an RN, PT or OT.In an interview on 01/19/22 at 12:30 pm, Staff 16 (RN) stated no assessment had been completed for Resident 5's siderails.The lack of an assessment for the resident's siderails was discussed with Staff 3 (Regional Director of Operations) and Staff 17 (RCC) on 01/20/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Division. Findings include, but are not limited to:Refer to C 252, C 340, Z 155 and Z 162.
Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Division. Findings include, but are not limited to:Refer to Z 155.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired staff (# 8) completed pre-service training prior to independently providing personal care for residents. Findings include, but are not limited to:Review of the facility's training records on 10/20/21 revealed the following:The facility lacked documented evidence Staff 8 (CG), hired 06/29/21 completed all required pre-service training topics including: * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;* Environmental factors that are important to a resident's well-being; and* Family support and the role the family may have in the care of the resident.The need to ensure newly hired staff completed pre-service training with all required elements was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 3 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 18 and 19) completed pre-service training prior to independently providing personal care to residents. This is a repeat citation. Findings include, but are not limited to:On 01/19/22, training records were reviewed with Staff 4 (Business Office Manager).The facility lacked documented evidence Staff 18 (CG), hired 11/14/21 and Staff 19 (CG, hired 09/22/21, completed all required six hours of pre-service dementia care training topics including: * Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms; * 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;* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; * Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: identify and address pain; provide food and fluid; prevent wandering and elopement; and use a person-centered approach;* Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* How to provide personal care to a resident with dementia, including an orientation to the resident and the resident's service plan; and* The use of supportive devices with restraining qualities in memory care communities. The need to ensure newly hired staff completed pre-service training with all required elements was discussed with Staff 3 (Regional Director of Operations), Staff 4 (Business Office Manager and Staff 17 (RCC) on 01/20/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired staff (#23) completed pre-service training prior to independently providing personal care to residents. This is a repeat citation. Findings include, but are not limited to:On 03/14/22, training records were reviewed with Staff 4 (Business Office Manager).The facility lacked documented evidence Staff 23 (Med Tech) hired on 01/20/22 completed all required six hours of pre-service dementia care training topics including: * Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms; * 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;* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; * Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: identify and address pain; provide food and fluid; prevent wandering and elopement; and use a person-centered approach;* Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* How to provide personal care to a resident with dementia, including an orientation to the resident and the resident's service plan; and* The use of supportive devices with restraining qualities in memory care communities. The need to ensure newly hired staff completed pre-service training with all required elements and the training was documented and available for review was discussed with Staff 22 (Executive Director) Staff 3 (Regional Director of Operations), Staff 4 (Business Office Manager) and Staff 17 (RCC) on 03/14/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 252, C 260, C 262, C270, C 280, C 303, C 330 and C 340.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 252 and C 340.

Based on observation, 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 07/2021, with diagnoses including dementia, anxiety and hallucinations.Resident 3's record documented behaviors including:* Exit seeking and elopement attempt on 08/06/21; and* Was administered as needed Quetiapine for "behaviors" on three occasions between 10/01/21 and 10/18/21.During an interview with Staff 11 (CG) on 10/19/21, she reported Resident 3 experienced hallucinations of seeing a family member with no extremities and seeing snakes on the floor. Staff 11 stated the resident experienced anxiety manifested by pacing, crying, rummaging through belongings, packing and anxiously standing at his/her door.The resident's current service plan did not address these behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of these behaviors. The need to include an individualized behavior plan for residents with behavioral symptoms was discussed with Staff 1 (Administrator), Staff 2 (MT/Life Enrichment Director) and Staff 4 (Regional Director of Operations) on 10/20/21. They acknowledged the findings.