Waterhouse Ridge Memory Care Community

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 resident care needs, provided clear direction regarding the delivery of services, and were implemented for 2 of 4 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 02/2024 with diagnoses including dementia, peripheral vascular disease, and late onset Alzheimer’s disease. The resident’s 12/03/25 through 03/02/26 clinical record was reviewed. Observations of the resident were made, and interviews were conducted with staff. The 09/24/25 and 03/02/26 service plan and 01/06/26 to 02/28/26 temporary service plans were not reflective of the resident’s current status, lacked clear instructions for staff, or were not implemented in the following areas: * Use of a cushion while in the wheelchair; * Eating status, including the level of staff assistance required during meals; * Use of a gait belt during transfers; * Instructions/precautions to staff regarding use of a half-length side rail; * Use of a floor mattress, including when the mattress should be in place; * Compression stockings; * Use of overhead trapeze; * Incontinence care status; * Shower status, including responsibility for providing the service -- hospice team versus facility staff members; and * Fall prevention interventions. During the acuity interview on 03/02/26, staff reported the resident had frequent falls. The 09/24/25 and 03/02/26 service plan showed the resident required two-staff members’ assistance for transfers using a gait belt, two-staff members’ assistance for all ADLs, and one staff member to assist with applying and removing compression stockings daily. During an observation on 03/02/26, two staff members assisted the resident with a transfer and incontinence care without using a gait belt. Meal observations on 03/02/26 and 03/03/26 showed the resident needed physical assistance to maintain intake and complete meals, and s/he was not observed wearing compression stockings. Additionally, the resident was observed in a hospital bed; at times, a half-length side rail was in the raised position, and at other times, it was in the lowered position. On 03/03/26 at approximately 8:50 am, Staff 17 (CG) reported she was unsure when the half-length side rail should be used. Staff 18 (CG) reported she had previously observed the resident using the half-length side rail to assist with turning and bed mobility. Staff 18 further stated the half-length side rails were not to be used because they functioned as a restraint for the resident. On 03/03/26 at approximately 3:24 pm, Staff 14 (CG) and Staff 20 (CG) reported that the half-length side rails should be raised when the resident was in bed. The need to ensure service plans were reflective of the resident’s status, provided clear direction to staff regarding the delivery of services, and were implemented was reviewed with Staff 1 (ED), Staff 2 (Health Service Director/LPN), Staff 3 (RCC), Staff 4 (RCC), Staff 6 (Regional RN), and Staff 7 (VP of clinical Operations) on 03/04/26 at 11:16 am. They acknowledged the findings. 2. Resident 4 moved into the MCC in 01/2025 with diagnoses including dementia and had a history of falls. Staff reported in the acuity interview on 03/02/26 the resident used side rails on his/her bed to help prevent falls. The resident’s 11/28/25 to 02/27/26 clinical record was reviewed, observations of the resident were made, and staff were interviewed. The 01/16/26 service plan and 11/28/25 to 02/27/26 temporary service plans were not reflective of the resident’s needs and/or did not provide clear direction to staff in the following areas: * Pain, including left knee and back pain and need for wheelchair when having pain; * Food and liquid preferences and level of assistance needed at meals; * Whether the resident’s door should be open for safety due to high fall risk; and * Instructions/precautions to staff regarding use of bilateral half-length side rails. Observations of the resident during meals on 03/02/26 and 03/03/26 showed the resident needed assistance to initiate eating, cut up food, and maintain attention to eating. In an interview at 12:25 pm on 03/02/26, Staff 23 (CG) stated the resident’s favorite beverage was hot chocolate. She also stated s/he sometimes refused meals offered but could not verbalize preference for an alternative, so staff offered him/her choices. Resident 4 was observed sleeping in a hospital bed at 8:28 am on 03/03/26, with bilateral half-length side rails in the down position. In an interview at 8:51 am on 03/03/26, Staff 15 (CG) stated the resident did not use the side rails. In an interview at 3:36 pm on 03/03/26, Staff 9 (MT) stated the resident used the side rails while in bed for fall prevention, as s/he had fallen out of bed while sleeping. The need to ensure the service plan was reflective of the resident’s needs and preferences and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RCC), Staff 4 (RCC), Staff 6 (Regional RN), and Staff 7 (VP of Clinical Operations) at 11:11 am on 03/04/26. They acknowledged the findings.

Plan of Correction – C0260 1. What actions will be taken to correct the rule violation for each example/resident? For all cited residents (Resident #1 and Resident #4), corrective actions were completed immediately. A comprehensive clinical reassessment was conducted by the Health Services Director (LPN) in collaboration with the RCC to ensure all current care needs, risks, and preferences were accurately identified. Service plans and Temporary Service Plans (TSPs) were revised to reflect the resident’s current status and required care, including gait belt use for all transfers, clear instructions for side rail use including when it is appropriate and safety precautions, wheelchair cushion use, meal assistance level including initiation and physical assistance, compression stocking application and removal, incontinence care needs, shower responsibilities between hospice and facility staff, floor mattress use including when it should be in place, trapeze use, individualized fall prevention interventions, pain management, and food preferences. All interventions were rewritten in clear, step-by-step language to ensure staff understanding and proper implementation. Direct care staff were re-educated on updated service plans prior to the next shift. Return demonstrations were completed for transfers and gait belt use. An audit of care implementation was completed through observation to ensure staff followed the updated service plans, including transfers and meal assistance. Physicians and POAs were notified as appropriate. All corrections were completed by: __________ 2. How will the system be corrected so this violation will not happen again? The facility has implemented system changes to ensure ongoing compliance. A standardized service plan format has been implemented requiring clear, task-specific instructions that outline how care is to be provided, when it is to be provided, and by whom. All required equipment such as gait belts, side rails, and trapeze must be clearly addressed. Staff assistance levels for all ADLs must be defined, along with safety precautions including fall prevention. A side rail and equipment clarification process has been implemented to ensure service plans clearly define the purpose of use, when the equipment should be in use, and required safety precautions. Staff have been educated on the difference between enablers and restraints to ensure compliance with Oregon regulations. The change of condition process has been reinforced to require immediate nurse assessment, same-day initiation of a Temporary Service Plan, and prompt updating of the permanent service plan to reflect ongoing needs. A Service Plan Audit Tool has been implemented to ensure plans are reflective of the resident’s current condition, aligned with observed care, and inclusive of all required interventions. Staff have completed retraining on service plan implementation, gait belt use, fall prevention, and meal assistance. New staff will complete competency validation prior to working independently. Clinical oversight has been strengthened. RCCs are responsible for documentation accuracy and service plan updates. The nurse is responsible for clinical validation and oversight. Daily clinical stand-up meetings have been implemented to review changes in condition, falls, and required service plan updates. 3. How often will the area needing correction be evaluated? Weekly audits of all service plans were conducted for four weeks following the survey. Monthly audits will be conducted thereafter to ensure ongoing compliance. Daily spot checks will be conducted to monitor transfers, including gait belt use, meal assistance, and fall prevention interventions. Quarterly service plan reviews will be tracked to ensure completion every 90 days in accordance with Oregon requirements. All identified issues will be corrected immediately upon discovery. 4. Who will be responsible to see that the corrections are completed/monitored? The Health Services Director (LPN/DHW) is responsible for overall clinical oversight, ensuring service plans reflect current resident conditions, conducting audits, and providing staff education. Resident Care Coordinators are responsible for service plan updates, documentation accuracy, and ensuring Temporary Service Plans are initiated and transitioned appropriately. The Executive Director is responsible for administrative oversight and ensuring compliance systems are maintained. The Regional Nurse and VP of Clinical Operations provide additional oversight, review audit outcomes, and ensure sustained compliance.

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

Based on observation, interview, and record review, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 1 and 2) who received incontinence care and for multiple unsampled residents during medication administration. Findings include, but are not limited to: 1. Throughout the re-licensure survey, from 03/02/26 through 03/04/26, the following observations were made to determine adherence to universal precautions for infection control: a. Resident 2 moved into the MCC in 01/2022 with diagnoses including Alzheimer’s disease. Per the service plan, dated 02/13/26, Resident 2 was dependent on two staff members to provide incontinence care. Two observations were made of caregivers providing incontinence care for Resident 2. Staff 11 (CG) and Staff 21 (CG) were observed on 03/02/26 at 12:55 pm, and Staff 21 and Staff 13 (CG) were observed on 03/03/26 at 8:47 am. During both observations, Staff 11, Staff 13, and Staff 21 entered the resident’s room and donned gloves without first performing hand hygiene. On 03/02/26, Staff 11 removed a soiled brief, assisted Resident 2 with perineal care, doffed gloves, donned new gloves, and re-positioned the resident in bed without completing hand hygiene between dirty and clean tasks. Staff 11 left the unit without completing hand hygiene. On 03/03/26, Staff 21 removed the resident’s soiled brief and tossed it on the bathroom floor. With soiled gloves, Staff 21 turned on the bathroom sink and obtained incontinence wipes. Staff 21 doffed and then donned new gloves without performing hand hygiene, performed additional perineal care, and doffed gloves without performing hand hygiene between dirty and clean tasks. b. Observations of medications passes were made on 03/03/26 at 12:15 pm. Staff 10 (MT) was observed pouring and passing medications, touching a computer and the medication cart, pouring a single pill into her hand prior to handing it to the resident, grabbing a resident’s used lunch spoon to administer a pill, entering a resident’s room, grabbing an unused medication cup and water cup by placing her finger in the cups and then restocking them to be used later without changing gloves and/or performing hand hygiene between dirty and clean tasks. The need to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment during ADL care and during medication administration was discussed with Staff 1 (ED), Staff 2 (Health Service Director/LPN), Staff 3 (RCC), Staff 4 (RCC), Staff 6 (Regional RN), and Staff 7 (VP of Clinical Operations) on 03/04/26 at 11:45 am. They acknowledged the findings. 2. Observations were made during the survey, from 03/02/26 through 03/03/26, to determine adherence to universal precautions for infection control. Resident 1 moved into the MCC in 02/2024 with diagnoses including dementia, peripheral vascular disease, and late onset Alzheimer’s disease. On 03/02/26 at approximately 1:23 pm, the surveyor obtained permission and observed Staff 16 (CG) and Staff 17 (CG), and on 03/03/26 at approximately 8:38 am, Staff 17 and Staff 18 (CG), provide incontinence care to Resident 1. During the observations, Staff 16, Staff 17, and Staff 18 failed to change gloves after removing a soiled incontinence product and wiping the resident’s bottom area. Staff 16, Staff 17, and Staff 18 applied a new brief to the resident and touched the resident's pants and the manual wheelchair while wearing the same soiled gloves. When Staff 16, Staff 17, and Staff 18 were finished providing incontinence care they removed the gloves. During the observations, staff failed to change gloves between clean and dirty tasks. The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED), Staff 2 (Health Service Director/LPN), Staff 3 (RCC), Staff 4 (RCC), Staff 6 (Regional RN), and Staff 7 (VP of clinical Operations) on 03/04/26 at 11:16 am. They acknowledged the findings.

Plan of Correction – C0295 1. What actions will be taken to correct the rule violation for each example/resident? For Residents #1 and #2, as well as all other residents receiving care, immediate corrective actions were taken. A full review of infection control practices was conducted by the Health Services Director (LPN) and leadership team. All staff involved were immediately re-educated on proper infection prevention and control protocols, including hand hygiene, glove use, and prevention of cross-contamination. Return demonstrations were completed with all caregiving and medication staff to ensure proper technique, including performing hand hygiene before and after resident care, changing gloves between dirty and clean tasks, and avoiding contamination of clean supplies and surfaces. Incontinence care procedures were corrected to require hand hygiene before donning gloves, between dirty and clean tasks, and after glove removal. Staff were instructed not to touch clean surfaces or supplies with soiled gloves and to properly dispose of soiled briefs in designated receptacles. Medication administration practices were corrected to ensure staff perform hand hygiene and/or glove changes between tasks, avoid touching medications with bare hands, avoid contamination of medication cups and supplies, and maintain clean technique throughout medication pass. All residents were assessed for any potential adverse outcomes related to infection control breaches. No negative outcomes were identified at the time of review. All corrections were completed by: Clinical Team 2. How will the system be corrected so this violation will not happen again? The facility has implemented the following system changes to ensure ongoing compliance with infection prevention and control requirements. An Infection Control Specialist has been designated and meets qualifications as required by OAR. The designee has completed or is scheduled to complete required infection control training within the required timeframe. A standardized infection control protocol has been reinforced and includes clear expectations for hand hygiene, glove use, clean versus dirty task separation, and prevention of cross-contamination during both ADL care and medication administration. A mandatory infection control in-service was conducted for all staff, including caregivers and medication technicians, with emphasis on universal precautions, proper glove use, and hand hygiene compliance. A competency-based training program has been implemented requiring all staff to demonstrate proper infection control practices prior to working independently. Visual reminders and infection control signage have been placed in staff areas and medication rooms to reinforce expectations. Medication administration processes have been revised to ensure clean technique is maintained at all times, including proper handling of medication cups, avoidance of hand-to-medication contact, and required hand hygiene between residents and tasks. A monitoring system has been implemented, including routine observation of staff during care and medication passes to ensure adherence to infection control practices. 3. How often will the area needing correction be evaluated? Daily observations of caregiving and medication administration practices was conducted for four weeks following the survey. Weekly audits will be conducted for infection control compliance, including hand hygiene, glove use, and adherence to clean versus dirty task protocols. Monthly infection control audits will be conducted thereafter to ensure ongoing compliance. Competency validation will be completed for all new hires prior to independent work and re-evaluated annually. All identified concerns will be addressed immediately upon discovery. 4. Who will be responsible to see that the corrections are completed/monitored? The Health Services Director (LPN/DHW) is responsible for overall infection control oversight, staff training, competency validation, and audit completion. The designated Infection Control Specialist is responsible for implementation and ongoing monitoring of infection prevention and control protocols and serving as the point of contact for infection-related concerns. Resident Care Coordinators are responsible for reinforcing infection control practices during daily operations and ensuring staff adherence. The Executive Director is responsible for ensuring systems are in place and maintained for compliance. The Regional Nurse and VP of Clinical Operations provide additional oversight, review audit results, and ensure sustained compliance.

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

OAR 411-054-0090 (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 conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: On 03/02/26, fire drill and fire and life safety records for the previous six months were requested. Review of the documentation provided revealed the following: Staff were not evacuating or relocating residents during fire drills; therefore, the facility's fire drill documentation did not include information on escape route used, problems encountered, and comments relating to residents who resisted or failed to participate in the drills, and number of occupants evacuated. In an interview on 03/03/26 at 11:00 am, Staff 5 (Physical Plant Director) confirmed the facility staff were not evacuating or relocating residents during fire drills. The requirements regarding fire drills were discussed with Staff 5 on 03/03/26 at 11:16 am, and Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RCC), Staff 4 (RCC), Staff 6 (Regional RN), and Staff 7 (VP of Clinical Operations) on 03/04/26 at 11:31 am. They acknowledged the findings.

POC C420 What Actions will be taken to correct the rule violations for each example? Staff were not evacuating or relocating residents during fire drills: Therefor Facility fire drill documentation did not include info on escape route used, problems encountered and comments relating to residents who resisited or failed to participate in drill and number of occupants evacuated. Immediately after this survey the Maintenance Director contacted our local Fire Marshall to get documentation on the rule. Our company was still under the impression that we were to shelter in place. We received the Fire Marshall documentation that shelter in place was not longer acceptable and residents in the fire area needed to be evacuated or moved beyond the fire doors to a safe area. This info was sent to our Home office and our frire drill form that is required for our drills was immediately updated to include a section that gives a place to document What escape route was used, how many occupants were moved or evacuated, residents who resisited or failed to participate. This form is now being used company wide for all fire drills. Clinical team has been educated that if we have a resident who is coninually resisitant to evacuating that this info will be documented into their service plan. We held an al staff meeting on March 19th where the new procedure was gone over with all staff and what they are to do when they hear the fire alarm go off and how to move residents and to lock and mark their doors once a room is cleared. This was gone over verbally at all staff and also printed and passed out at al lstaff. 2. How will the system be corrected so that this violation will not happen again? We use tels as our system that schedules our yearly fire drills. The Maintenance Director looks at his Tels tasks daily to know what regulatory items is needed to be done for that month. All of our fire drill sfor the 3 different shaits are scheduled in this system. The new form is downloaded into Tels and is attached to each scheduled fire drill. This reminds the maintenance man that he must use this form and fill it out completely and upload back into Tels as proof the task was completed along with staff signature log. The form has been updated so that anyone who does the drill will have the correct form to fill out with all required info. 3.How often will the area be evaluated? We do fire drills every other month. When they are due the Maintenance Director will conduct the drill and the ED will be the final staff to sign off and at that time the ED will verify that all required info has been filled out and that residents were moved or evacuated during each drill. 4. Who will be responsible to see that the corrections are completed and monitored? The ED has already verified that the form and the staff education has been completed. The ED will also verify at every fire drill that residents were evacuated and moved and the ED will verify that all info is filled out on the drill form that will be uploadced.

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 411-057-0140(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. Refer to: C295 and C420.

Tag Z142 Community will follow the POC outlined under tag C295 and C 420 C295 POC Plan of Correction – C0295 1. What actions will be taken to correct the rule violation for each example/resident? For Residents #1 and #2, as well as all other residents receiving care, immediate corrective actions were taken. A full review of infection control practices was conducted by the Health Services Director (LPN) and leadership team. All staff involved were immediately re-educated on proper infection prevention and control protocols, including hand hygiene, glove use, and prevention of cross-contamination. Return demonstrations were completed with all caregiving and medication staff to ensure proper technique, including performing hand hygiene before and after resident care, changing gloves between dirty and clean tasks, and avoiding contamination of clean supplies and surfaces. Incontinence care procedures were corrected to require hand hygiene before donning gloves, between dirty and clean tasks, and after glove removal. Staff were instructed not to touch clean surfaces or supplies with soiled gloves and to properly dispose of soiled briefs in designated receptacles. Medication administration practices were corrected to ensure staff perform hand hygiene and/or glove changes between tasks, avoid touching medications with bare hands, avoid contamination of medication cups and supplies, and maintain clean technique throughout medication pass. All residents were assessed for any potential adverse outcomes related to infection control breaches. No negative outcomes were identified at the time of review. All corrections were completed by: Clinical Team 2. How will the system be corrected so this violation will not happen again? The facility has implemented the following system changes to ensure ongoing compliance with infection prevention and control requirements. An Infection Control Specialist has been designated and meets qualifications as required by OAR. The designee has completed or is scheduled to complete required infection control training within the required timeframe. A standardized infection control protocol has been reinforced and includes clear expectations for hand hygiene, glove use, clean versus dirty task separation, and prevention of cross-contamination during both ADL care and medication administration. A mandatory infection control in-service was conducted for all staff, including caregivers and medication technicians, with emphasis on universal precautions, proper glove use, and hand hygiene compliance. A competency-based training program has been implemented requiring all staff to demonstrate proper infection control practices prior to working independently. Visual reminders and infection control signage have been placed in staff areas and medication rooms to reinforce expectations. Medication administration processes have been revised to ensure clean technique is maintained at all times, including proper handling of medication cups, avoidance of hand-to-medication contact, and required hand hygiene between residents and tasks. A monitoring system has been implemented, including routine observation of staff during care and medication passes to ensure adherence to infection control practices. 3. How often will the area needing correction be evaluated? Daily observations of caregiving and medication administration practices was conducted for four weeks following the survey. Weekly audits will be conducted for infection control compliance, including hand hygiene, glove use, and adherence to clean versus dirty task protocols. Monthly infection control audits will be conducted thereafter to ensure ongoing compliance. Competency validation will be completed for all new hires prior to independent work and re-evaluated annually. All identified concerns will be addressed immediately upon discovery. 4. Who will be responsible to see that the corrections are completed/monitored? The Health Services Director (LPN/DHW) is responsible for overall infection control oversight, staff training, competency validation, and audit completion. The designated Infection Control Specialist is responsible for implementation and ongoing monitoring of infection prevention and control protocols and serving as the point of contact for infection-related concerns. Resident Care Coordinators are responsible for reinforcing infection control practices during daily operations and ensuring staff adherence. The Executive Director is responsible for ensuring systems are in place and maintained for compliance. The Regional Nurse and VP of Clinical Operations provide additional oversight, review audit results, and ensure sustained compliance. C240 POC POC C420 What Actions will be taken to correct the rule violations for each example? Staff were not evacuating or relocating residents during fire drills: Therefor Facility fire drill documentation did not include info on escape route used, problems encountered and comments relating to residents who resisited or failed to participate in drill and number of occupants evacuated. Immediately after this survey the Maintenance Director contacted our local Fire Marshall to get documentation on the rule. Our company was still under the impression that we were to shelter in place. We received the Fire Marshall documentation that shelter in place was not longer acceptable and residents in the fire area needed to be evacuated or moved beyond the fire doors to a safe area. This info was sent to our Home office and our frire drill form that is required for our drills was immediately updated to include a section that gives a place to document What escape route was used, how many occupants were moved or evacuated, residents who resisited or failed to participate. This form is now being used company wide for all fire drills. Clinical team has been educated that if we have a resident who is coninually resisitant to evacuating that this info will be documented into their service plan. We held an al staff meeting on March 19th where the new procedure was gone over with all staff and what they are to do when they hear the fire alarm go off and how to move residents and to lock and mark their doors once a room is cleared. This was gone over verbally at all staff and also printed and passed out at al lstaff. 2. How will the system be corrected so that this violation will not happen again? We use tels as our system that schedules our yearly fire drills. The Maintenance Director looks at his Tels tasks daily to know what regulatory items is needed to be done for that month. All of our fire drill sfor the 3 different shaits are scheduled in this system. The new form is downloaded into Tels and is attached to each scheduled fire drill. This reminds the maintenance man that he must use this form and fill it out completely and upload back into Tels as proof the task was completed along with staff signature log. The form has been updated so that anyone who does the drill will have the correct form to fill out with all required info. 3.How often will the area be evaluated? We do fire drills every other month. When they are due the Maintenance Director will conduct the drill and the ED will be the final staff to sign off and at that time the ED will verify that all required info has been filled out and that residents were moved or evacuated during each drill. 4. Who will be responsible to see that the corrections are completed and monitored? The ED has already verified that the form and the staff education has been completed. The ED will also verify at every fire drill that residents were evacuated and moved and the ED will verify that all info is filled out on the drill form that will be uploadced.

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

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

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

Tag Z162 community will follow POC outlined under C260 POC 260 Plan of Correction – C0260 1. What actions will be taken to correct the rule violation for each example/resident? For all cited residents (Resident #1 and Resident #4), corrective actions were completed immediately. A comprehensive clinical reassessment was conducted by the Health Services Director (LPN) in collaboration with the RCC to ensure all current care needs, risks, and preferences were accurately identified. Service plans and Temporary Service Plans (TSPs) were revised to reflect the resident’s current status and required care, including gait belt use for all transfers, clear instructions for side rail use including when it is appropriate and safety precautions, wheelchair cushion use, meal assistance level including initiation and physical assistance, compression stocking application and removal, incontinence care needs, shower responsibilities between hospice and facility staff, floor mattress use including when it should be in place, trapeze use, individualized fall prevention interventions, pain management, and food preferences. All interventions were rewritten in clear, step-by-step language to ensure staff understanding and proper implementation. Direct care staff were re-educated on updated service plans prior to the next shift. Return demonstrations were completed for transfers and gait belt use. An audit of care implementation was completed through observation to ensure staff followed the updated service plans, including transfers and meal assistance. Physicians and POAs were notified as appropriate. All corrections were completed by: __________ 2. How will the system be corrected so this violation will not happen again? The facility has implemented system changes to ensure ongoing compliance. A standardized service plan format has been implemented requiring clear, task-specific instructions that outline how care is to be provided, when it is to be provided, and by whom. All required equipment such as gait belts, side rails, and trapeze must be clearly addressed. Staff assistance levels for all ADLs must be defined, along with safety precautions including fall prevention. A side rail and equipment clarification process has been implemented to ensure service plans clearly define the purpose of use, when the equipment should be in use, and required safety precautions. Staff have been educated on the difference between enablers and restraints to ensure compliance with Oregon regulations. The change of condition process has been reinforced to require immediate nurse assessment, same-day initiation of a Temporary Service Plan, and prompt updating of the permanent service plan to reflect ongoing needs. A Service Plan Audit Tool has been implemented to ensure plans are reflective of the resident’s current condition, aligned with observed care, and inclusive of all required interventions. Staff have completed retraining on service plan implementation, gait belt use, fall prevention, and meal assistance. New staff will complete competency validation prior to working independently. Clinical oversight has been strengthened. RCCs are responsible for documentation accuracy and service plan updates. The nurse is responsible for clinical validation and oversight. Daily clinical stand-up meetings have been implemented to review changes in condition, falls, and required service plan updates. 3. How often will the area needing correction be evaluated? Weekly audits of all service plans were conducted for four weeks following the survey. Monthly audits will be conducted thereafter to ensure ongoing compliance. Daily spot checks will be conducted to monitor transfers, including gait belt use, meal assistance, and fall prevention interventions. Quarterly service plan reviews will be tracked to ensure completion every 90 days in accordance with Oregon requirements. All identified issues will be corrected immediately upon discovery. 4. Who will be responsible to see that the corrections are completed/monitored? The Health Services Director (LPN/DHW) is responsible for overall clinical oversight, ensuring service plans reflect current resident conditions, conducting audits, and providing staff education. Resident Care Coordinators are responsible for service plan updates, documentation accuracy, and ensuring Temporary Service Plans are initiated and transitioned appropriately. The Executive Director is responsible for administrative oversight and ensuring compliance systems are maintained. The Regional Nurse and VP of Clinical Operations provide additional oversight, review audit outcomes, and ensure sustained compliance.

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 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 02/24/26 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas: * Floor beneath stove/grill and steamer – build up of black debris; * Top of dishwasher – build up of dried debris; * Wall under spray hose sink and behind dishwasher – build up of brown matter; * Wall above three compartment sinks – build up of dust; * Ceiling vents and surrounding ceiling above refrigeration units and near dishwasher – build up of dust; and * Side of grill – food spills/splatters. Other concerns included: * Two door refrigerator across from steam table – seal on bottom of door not connected; and * Commercial can opener – blade finish worn off. The areas of concern were discussed with Staff 1 (Director of Dining Services) on 02/24/26. The findings were acknowledged at 12:15 pm.

Tag C240 – Food Sanitation (OAR 333-150-0000) 1. Corrective Action for Specific Instances Identified On 02/25/2026, immediately following the exit conference, the following corrective actions were started: * The floor beneath the stove/grill and steamer was pulled out and deep cleaned to remove black debris. * The top of the dishwasher was cleaned and sanitized. * The wall under the spray hose sink and behind the dishwasher was cleaned and sanitized. * The wall above the three-compartment sink was cleaned to remove dust accumulation. * Ceiling vents and surrounding ceiling areas above refrigeration units and near the dishwasher were cleaned. * The side of the grill was degreased and sanitized to remove food splatters. * The two-door refrigerator gasket seal was ordered and when it is delivered maintenance will reattch before 3/15/26 * The commercial can opener blade will be replaced before 3/15/26 All cited areas were cleaned, repaired, or replaced by 3/2/26 2. Systemic Changes to Prevent Recurrence To ensure ongoing compliance with OAR 333-150-0000: * A revised Kitchen Deep Cleaning Schedule has been implemented effective 3/3/26 * Daily, weekly, and monthly cleaning assignments now include: * Moving and cleaning beneath cooking equipment * Cleaning tops of equipment * Cleaning walls behind and above sinks * Cleaning ceiling vents * A Preventative Maintenance Log has been implemented to monitor: * Refrigerator gaskets and seals (monthly inspection) * Small wares and equipment condition (including can opener blades) * The Director of Dining Services (DDS) will complete and sign off on a weekly sanitation audit checklist. * The Executive Director or designee will conduct a random monthly environmental sanitation audit for oversight. 3. Monitoring of Ongoing Compliance * Weekly kitchen sanitation audits will be completed by the DDS and reviewed by the Executive Director. * Monthly administrative oversight audits will be documented and retained for review. * Any identified concerns will be corrected immediately and documented. * Sanitation logs will be maintained for no less than 12 months. 4. Staff Training * All dietary staff were retrained on: * Oregon Food Sanitation Rules (OAR 333-150-0000) * Cleaning and sanitizing standards * Equipment maintenance reporting procedures * Training will be completed by completed 3/15/26 * New hires will receive sanitation protocol training during orientation. * Refresher training will occur quarterly.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

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

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

Tag Z0142 – Administration Compliance (OAR 411-057-0140(2)) Corrective Action As Z0142 is derivative of C240: * Administrative oversight systems have been strengthened to ensure ongoing compliance with Residential Care and Assisted Living licensing rules. * The Executive Director has implemented a structured monthly environmental compliance review process. * A compliance binder has been created to house sanitation logs, maintenance records, and audit tools for survey readiness. Monitoring * Monthly compliance review meetings will be conducted with the Director of Dining Services. * Findings will be documented and corrective action taken immediately if needed. Date of Alleged Compliance: 03/15/2026 The facility alleges compliance with OAR 411-057-0140(2) by 03/15/2026.

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

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 03/19/25 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas: * Under counter two door refrigerator – interior drips/spills of juice; * Three – two door refrigerators – exterior doors with spills/smears/drips; interior fans of two refrigerators had fan cages with heavy build up of dust and/or black matter; bottom shelves with food debris/crumbs/spills; * Upright two door freezers – exterior doors with smears/drips, vent below doors with build up of dust; interior bottom shelves with food debris/crumbs; * Ice maker – vent heavily build up of dust; * Flooring throughout the kitchen, especially underneath cooking equipment, refrigeration units, steam table, dishwasher, three sink area and prep counter – build up of black/brown matter, drips/spills/debris; * Ceiling vents and surrounding ceiling areas throughout the entire kitchen – heavy build up of dust; * Lower and upper shelving of prep counters throughout the kitchen and steam table – drips/smears/debris; * Lower shelving on front side of steamtable, including the end – drips/smears/debris; * Dishwashing area: wall and caulking above the backsplash and behind spray hose, three sink area, wall below spray hose sink, three sinks area and side wall – build up of black/brown/pink matter and drips/spills; * Exterior of dishwashing machine - build up of drips/spills; * Signage posted on wall in dishwashing area – heavy build up of dust; * Hood vents above cooking equipment – dusty/grease build up; * Oven doors and sides of oven – drips/spills; * Steam exterior – drips/spills; * Wall next to and behind steam – drips/spills/grease; and * Commercial stand mixer and counter – back splash area heavily soiled with food matter and debris underneath on counter. Other concern: * Colored cutting boards – finish worn “white” and heavily scored. The areas of concern were observed and discussed with Staff 1 (Culinary Director and discussed with Staff 2 (Interim Executive Director) on 03/19/25. The findings were acknowledged.

The facility failed to ensure kitchen practices and protocols were followed in accordance with regulatory requirements. Corrective Actions Taken: 1. All areas of the kitchen identified in the deficiency have undergone a deep cleaning. 2. All vents have been removed, thoroughly cleaned, and reinstalled. 3. All shelving has been wiped down and deep cleaned. 4. The dishwashing area has been re-caulked and deep cleaned. 5. The dishwashing machine has been cleaned to remove any buildup, spills, and drips. 6. Hoods, vents, walls, and doors have been deep cleaned to maintain sanitary conditions. 7. New color-coded cutting boards have been ordered and are expected to arrive by April 4, 2025. Measures to Prevent Recurrence: • A routine deep-cleaning schedule has been implemented, with assigned responsibilities and documentation logs. • Staff has been re-educated on proper kitchen sanitation and maintenance protocols to ensure compliance. • The facility’s kitchen will undergo weekly inspections by the Culinary Director or designee to ensure ongoing adherence to cleaning and sanitation requirements. • Upon arrival, the new color-coded cutting boards will be integrated into daily kitchen operations, and staff will be trained on their proper use and sanitation. The Executive Director or Designee will be responsible for ensurieng all process are being followed.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

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

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

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.

The findings of the on-site investigation, conducted 04/30/24 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 and 57 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure the quality of care and services rendered in the facility based on the number and severity of citations. Findings include, but are not limited to: Refer to deficiencies in the report.

C-150 Facility Administration: Operation o Refer to other deficiencies in the report. 160 Reasonable Precautions 1. The diet order for resident 3 was communicated to staff via TSP and the correct diet order was confirmed with the kitchen. 2. Orders are being reviewed daily by nursing to ensure timely processing of orders. A full list of diet orders will be reviewed monthly in the QI meeting. 3. Orders will be reviewed daily in the clinical meeting, and orders processed in the third check system.   4. Administrator and Nurse.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (# 3) who had a delay in implementation of physician-ordered diet texture . Findings include, but are not limited to: Resident 3's clinical records were reviewed, staff were interviewed, and observations of the resident were made during the period of the survey, 03/04/24 through 03/07/24. An order was received from the hospice provider on 02/19/24 to begin pureed diet texture effective 02/19/24 for Resident 3. A temporary service plan was provided to staff on 02/25/24 informing of the change in diet status, six days following the effective date of the diet texture change. During an interview on 03/07/24 at 10:10 am, Staff 9 confirmed she received the order "around" 02/25/24. Staff 9 was unsure why there was a delay of six days to receive and implement the updated diet status. Observations of the resident made during meal service throughout the period of the survey, 03/04/24 through 03/07/24, confirmed the correct diet texture was being provided to Resident 3. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents by implementing physician orders when received was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

C160 - Reasonable Precautions 1. Training for all staff on reasonable pre cautions focused on glove use, cross contaminiation and food service.   2. In service with staff prior to working with the floor  for Immediate assigned neighborhoods for CarePartners with sign off on task list - to be submitted to  Resident Care Coordinator with review with ED and Nurse. MOD through weekend - Director of Health Services.      3. Staff training will include monthly focus on reasonable precautions.   4. Administrator/Desginee

Based on observation and record review, it was determined the facility failed to create an environment in which residents were treated with dignity and respect, were free from neglect, and received services in a manner that protected privacy and dignity for 1 of 1 sampled resident (#2) who was bedbound. Findings include, but are not limited to: Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type 2 diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease. During the acuity interview on 03/04/24, Resident 2 was reported to be on hospice, with bedbound status, and on a pureed-texture diet requiring meal assist. 1. During observations on 03/04/24, the resident was lying in a hospital bed on his/her back, with his/her eyes closed, and in no apparent distress. The head of the bed was elevated at approximately 15 degrees. * At 12:28 pm, Staff 25 (Care Partner) brought a tray with a bowl of pureed food, placed it on the bedside table next to the resident, and exited the room; * At 1:21 pm, Staff 27 (MT) went into the room to administer medication to the resident. He was unable to arouse the resident and left the room at 1:25 pm stating, "Will come back."; * At 1:26 pm, the resident's lunch remained on the bedside table. Staff 25 was in the dining area standing in the kitchenette and was not involved in any resident-related activities. Facility lunch service was completed, and three residents were sitting in the dining area; * At 1:38 pm, Staff 3 (RCC) entered Resident 2's room and administered medications. He stated,"You'll get your lunch pretty soon" and exited the room; and * At 2:24 pm, Staff 25 came into the resident's room, picked up the lunch tray, and placed it in the refrigerator. Facility Care Partners recorded daily meal intake percentages for all residents on individual Weekly Meal Tracking sheets, which were kept in a binder located in the kitchenette area. Entries for lunch and dinner for Resident 2 were left blank for Monday, 03/04/24. 2. During observations on 03/04/24 through 03/06/24, on multiple occasions various facility care staff provided personal care to Resident 2 while either the window blinds or the door to the resident's room, or both, were open. The need to create an environment in which residents were treated with dignity and respect, were free from neglect, and received services in a manner that protected privacy and dignity was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. No further information was provided.

200 Resident Rights 1. The service plan for resident 2 was updated to include appropriate assistance needed for meals. Staff were provided with education on the need to provide a dignified experience and privacy when completing care tasks. The need to provide assistance with meals and privacy during care was reviewed with all staff. 2. All staff meeting is scheduled for April 18 to review proper assistance with meals and how to provide care with dignity and respect and provide for privacy. Resident rights will be reviewed at the all-staff and all-staff to complete Relias training modules for resident rights. RCC and administrator will complete routine walk-throughs to audit for compliance. Medtechs are being trained as manager on duty at mealtimes.   3. Daily monitoring by manager on duty, as well as RCC and administrator.   4. Administrator, nurse and RCC.

Based on interview and record review, it was determined the facility failed to report incidents of abuse and suspected abuse to the local Seniors and People with Disabilities (SPD) office, document investigations of abuse and suspected abuse including an administrator's review, and to report injuries, including injuries of unknown cause, as suspected abuse unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include but are not limited to: 1. Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia. Review of the resident's 12/05/23 through 03/04/24 progress notes, 12/27/23 service plan, and TSP's (Temporary Service Plans) revealed the following: * 01/09/24 - "Resident was upset that [his/her] roommate...and hospice Certified Nursing Assistant (CNA) ...were using the shared bathroom in their bedroom. Resident was shouting stating it was [his/her] bathroom and cursing at staff, the hospice CNA and roommate. As [roommate] and hospice CNA were leaving the bathroom, resident threw [his/her] milk at them and continued shouting and cursing..." Review of the investigation into the incident revealed the incident was not reported to the local SPD office and the investigation lacked documented evidence of an administrator' review. During a 03/05/24 interview, Staff 2 (Vice President of Operations) confirmed the incident was not reported to the local SPD office and the investigation into the incident lacked an administrator's review. The facility was directed to report the incident to SPD. Documentation was provided to the survey team that SPD had been notified on 03/05/24. On 03/07/24 the need to ensure reports of abuse and suspect abuse were immediately reported to the local SPD office and investigations into abuse and suspected abuse included an administrator review was discussed with Staff 2 and Witness 2 (RN Consultant). They acknowledged the findings. 2. Resident 3 moved to the facility in 03/2022 with brain stem stroke syndrome and Alzheimer's disease. Observations of the resident, interviews with staff, and review of the resident's 02/23/24 service plan, temporary service plans, progress notes, and incident investigations were completed and revealed the following: A progress note dated 02/14/24 noted the resident "was found on floor at 12:35 am" and had a "significant bruise below [his/her] left eye." An interview with Witness 2 (RN Consultant) and Staff 2 (Vice President of Operations) on 03/06/24 revealed there was no evidence a prompt investigation of the incident documenting all required elements had been completed, nor was there evidence the incident had been reported to the local SPD office when abuse and/or neglect was not ruled out. At the request of the survey team, the above incident was reported to the local SPD office and confirmation was received at 5:00 pm on 03/06/24. The need to ensure prompt incident investigations documented all required elements, including whether or not abuse and/or neglect could be ruled out, and incidents were reported to the local SPD office if not, was discussed with Staff 2 and Witness 2 on 03/07/24. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type 2 diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease. A review of the resident's clinical record between 12/05/23 and 03/03/24, observation of care between 03/04/24 and 03/07/24, and staff interviews identified the following: * The service plan, dated 12/20/23, indicated the resident "is oriented to person and knows who [his/her] [deceased spouse] is as well."; * Skin impairment in the form of a scab was noted by the surveyor on the resident's left shin while staff was providing personal care on 03/06/24 at 10:41 am; * There was no documented reference to skin impairments found in the resident's clinical records; and * During an interview on 03/06/24, Witness 2 (RN Consultant) stated, "Skin rounds and a list of wounds being monitored were on the whiteboard in the med room, and [the facility nurse], who was fired last week, erased all the info when she left . . . I know there was something on the left leg that we have been monitoring." The skin impairment on the resident's left shin represented an injury of unknown cause. There was no documented evidence the facility promptly investigated the injury to rule out abuse and/or neglect or reported it to the local SPD office as suspected abuse. The need to ensure resident incidents were promptly investigated by the facility to reasonably conclude and document that a physical injury was not the result of abuse, and reported to the local SPD office as needed, was reviewed with Staff 2 (Vice President of Operations) and Witness 2 on 03/07/24. They acknowledged the findings. No further information was provided.

231 Incident Reports 1. Incident reports for residents 1, 2 and 3 were reported to APS. 2. Consultants will provide training to all staff on what situations require incident reports and how to complete incident reports. Consultants to train on investigation and reporting of injuries of unknown cause. Consultant to review APS reporting and investigation process with administrator and new nursing team.   3. Incident reports will be reviewed daily in the clinical meeting. 4. Administrator and nurse.

Based on observation, interview and record review, it was determined the facility failed to report incidents of abuse and suspected abuse to the local Seniors and People with Disabilities (SPD) office, document investigations of abuse and suspected abuse, including injuries of unknown cause, as suspected abuse unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse for 1 of 4 sampled residents (#7) whose records were reviewed for medication errors and injuries of unknown cause. This is a repeat citation. Findings include but are not limited to: Resident 7 moved into the memory care community in 07/2020 with diagnoses including Alzheimer's disease and anxiety disorder. The resident's clinical record including incident reports, temporary service plans (TSP's), progress notes dated 05/07/24 through 07/08/24 and outside service provider notes for the same time period were reviewed during the survey. a. Resident 7's clinical record identified the following reportable incidents related to medication errors: * On 05/06/24 - An outside provider note indicated a medication error occurred when the resident was found with two fentanyl patches on his/her body; and * On 07/03/24 and 07/04/24 - An incident report indicated a medication error regarding Fentanyl patches occurred on both days. During an interview on 07/09/24 with Staff 37 (Regional Clinical Director) investigations for the above medication errors were requested. One incident report for both of the medication errors that occurred on 07/03/24 and 07/04/24 was reviewed and documented "neglect could not be ruled out." There was no documented evidence an investigation was completed for the medication error that occurred on 05/06/24. During an interview on 07/09/24 with Staff 37, survey requested the medication errors be reported to the local SPD office if the facility investigation determined neglect could not be ruled out. Verification of facility reporting the medication errors was received on 07/10/24 and 07/11/24. b. The following skin injuries of unknown cause were identified: * On 05/16/24 - An outside provider note indicated the resident had "scattered bruising on the anterior forearm"; * On 06/21/24 - An outside provider note indicated the resident had a "healing cut on the RT [right] hand"; and * During an interview and observation of personal care on 07/08/24, Staff 17 (Care Partner) reported the resident had a small skin tear on his/her right lower leg/shin area. The surveyor observed the area and saw a small band-aid covering a skin tear on the resident's right lower leg. Staff 17 and Staff 41 (Care Partner) both reported they didn't know how it occurred or who put the band-aid on the resident's leg. During the same observation, the resident presented with bruising to his/her left top of hand and wrist area. S/he also had an approximate two inch by one inch bruise on the left upper arm, near the elbow. Investigations for the above injuries were requested on 07/10/24 at 12:16 pm. The facility was unable to provide evidence that they immediately investigated the injuries to the resident's anterior forearm, right hand, right shin, left hand and upper arm and reasonably ruled out they were not the result of abuse or reported the injuries of unknown cause to the local SPD office as suspected abuse. During an interview on 07/11/24 with Staff 30 (Acting ED) and Staff 31 (ED) at approximately 12:01 pm, survey requested the above skin injuries of unknown cause be reported to the local SPD office as suspected abuse. Verification of reporting the skin injuries of unknown cause was received on 07/11/24, prior to survey exit. The need to ensure medication errors and skin injuries of unknown cause were investigated promptly to rule out abuse and to report the incidents to the local SPD office when abuse or suspected abuse could not be ruled out was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings.

Example A-Med error on 5/6/24 actually occurred on 5/2/24. Med error on 7/3/24 and 7/4/24.  Incident reports were completed, TSP's were in place, alert charting was completed.  No adverse outcome.  APS was notified of med error.  Investigation was completed.  Two medication technicians admitted to not following seven rights of medication administration.  In addition, there was a clerical error on the part of the Pharmacy that populated the medication daily instead of every three days.  The medication technicians recognized this and did not report it to the Health and Wellness director.  The Patches were also dated appropriately.  Outside service notes will go through third check system and be reviewed as a team in the clinical meeting. The error in the EMAR system was fixed. Med tech training was completed with all med techs and will be ongoing to prevent errors from happening again. Regional team is going med-tech competency check by LN and RCC. The consultant team will be reviewing all incident reports and providing feedback to the community team. C. Skin Concerns on 5/16/24, 6/21/24, 7/8/24 5/16/24 Scattered bruising to anterior forearm.   6/21/24 R hand abrasion 7/8/24 multiple injuries of unknown cause.  All incidents were reported to APS, IR's were completed, TSPs put in place, alert charting started by 7/11/24. 2.  The current system in place includes three check system and review of all pending medications completed by the Health and Wellness Director.  The first two checks are completed by Medication technicians.  In addition, all medication errors include an incident report.  If neglect and abuse is not able to be ruled out the Health and Wellness Director and/or the ED will report to APS for any med errors that occur.  Regional RN will provide training on Abuse and Neglect Reporting, Root Cause Analysis. For skin injuries of unknown origin including skin tears, bruising or abrasions.  Care Staff Training related to reporting changes in skin will be completed by Regional RN and community RN by 8/2/24. Regional RN will provide training on Abuse and Neglect Reporting and Root Cause Analysis, investigations of injuries of unknown cause and reporting requirement by 8/5/24. 3.  Regional RN to review incidents and alert charting weekly via zoom with community Executive Director, RN and Resident Care Coordinator. Daily incident report review in the clinical meeting with weekly compliance checks. 4.  ED and LN or Corporate RN.

2. Resident 5 was admitted to facility in 10/2021 with diagnoses including dementia. a. Resident 5's service plan was dated with an "effective date" of 02/23/24, each service area was updated on 08/20/23 or 10/16/23, and the evaluation occurred on 01/03/24. Therefore, the evaluation was not the basis of the resident's service plan. b. The most recent quarterly evaluation, dated 01/03/24, did not reflect documented changes of condition in the following areas: * Level of dressing assistance required; * Bathing status; * Personal hygiene status; * Nail care instruction; and * Level of toileting assistance needed. During an interview on 03/07/24, Staff 2 (Vice President of Operations) confirmed the "effective date" on the service plan was the date the service plan was last reviewed and updated by the facility, and the evaluation was not the basis of Resident 5's service plan. The need to ensure quarterly evaluations were used as the basis of the quarterly service plan was discussed with Staff 2 and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. 3. Resident 6 was admitted to facility in 10/2023 with diagnoses including dementia. The move-in evaluation failed to address the following areas: * Interests, hobbies, social, leisure activities; * Physical health status including list of medications and PRN use, visits to health practitioner(s); * Ability to use call system; * Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Complex medication regimen; and * Recent losses. The need to ensure move-in evaluations addressed all required elements was discussed on 03/07/24 with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant). They acknowledged the findings. 4. Resident 3 was admitted to facility in 03/2022 with diagnoses including Alzheimer's disease. Resident 3's service plan was dated with an "effective date" of 02/23/24, each service area was updated on 09/10/23 or 10/30/23, and the evaluation occurred on 12/12/23. Therefore, the evaluation was not the basis of the resident's service plan. The most recent quarterly assessment was completed on 12/12/23 and did not reflect documented changes in the following areas: * Toileting; * Use of psychotropic medication; and * Evacuation assistance needed. During an interview on 03/07/24, Staff 2 (Vice President of Operations) confirmed the "effective date" on the service plan was the date the service plan was last reviewed and updated by the facility, and the evaluation was not the basis of Resident 3's service plan. The need to ensure quarterly evaluations were used as the basis of the quarterly service plan was discussed with Staff 2 and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure evaluations were used as the basis to develop the resident's service plan for 3 of 5 sampled residents (#s 3, 4, and 5) whose quarterly evaluations were reviewed and failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 6) whose move-in evaluation was reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to facility in 01/2020 with diagnoses including dementia. a. Resident 4's service plan was dated with an "effective date" of 02/23/24, each service area was updated on 08/20/23 or 10/16/23, and the evaluation occurred on 01/03/24. Therefore, the evaluation was not the basis of the resident's service plan. b. The most recent quarterly evaluation, dated 01/03/23, was not updated in the following areas: * Use of hearing aids, * Use of assistive devices; and * Use of a psychotropic medication. During an interview on 03/07/24, Staff 2 (Vice President of Operations) confirmed the "effective date" on the service plan was the date the service plan was last reviewed and updated by the facility, and the evaluation was not the basis of Resident 4's service plan. The need to ensure quarterly evaluations were used as the basis of the quarterly service plan was discussed with Staff 2 and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

252 Evaluations   1. Residents 3, 4 and 5 evaluations updated to include all required elements of the Oregon evaluation. 2. The consultant will train on the use of the evaluation of checklist to ensure all necessary components addressed. Evaluation and service plan schedule is being implemented. Consultant will train on admission evaluation process when the restriction of admission condition is lifted. 3. Weekly audit of evaluation schedule. 4. Administrator and nurse.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were relevant to the needs and current conditions for 2 of 5 residents (#s 7 and 9) whose quarterly evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 moved into the memory care community in 07/2020 with diagnoses including Alzheimer's disease and anxiety disorder. The quarterly evaluation was reviewed, interviews were conducted, and the following was identified: a. The quarterly evaluation was not dated and there was no indication as to who completed the evaluation. b. The quarterly evaluation failed to accurately describe the resident's current status and condition in the following areas: * Use of suppository for bowel care management; * Use of psychotropic medications; * Use of tilt-in-space wheelchair; * Communication; and * Dietary texture (Regular diet verses mechanical soft). The need to ensure the quarterly evaluation accurately described the resident's current status and condition was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings. 2. Resident 9 moved into the memory care community in 10/2022 with diagnoses including dementia and congestive heart failure. The quarterly evaluation was reviewed, interviews were conducted, and the following was identified: The quarterly evaluation failed to accurately describe the resident's current status and condition in the following areas: * Sleep routine including use of recliner; * How resident expressed pain; * Nutrition habits and fluid preference; * Use of psychotropic or antipsychotic medication; and * Environmental factors including room temperature. The need to ensure the quarterly evaluation was reflective of the resident's current status and condition was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 39 (Quality Assurance RN), Witness 2  (Consultant), and Witness 8 (Consultant) on 07/11/24. They acknowledged the findings.

1.  Resident 7 Quarterly Evaluation was completed on 7/8/24 due to change in condition on 7/8/24.  The following areas were corrected- use of suppositories for bowel care, use of psychotropic medications, use of tilt back w/c, communication and dietary texture.   Resident 9 Quarterly Evaluation was completed on 7/12/24 with corrections made to the following areas-sleep routine including use of recliner, how the resident expresses pain, nutrition habits and fluid preference, use of psychotropic or antipsychotic medications and environmental factors including room temperature.   2.  On 7/24/24 Regional RN provided 2.5 hours of training related to quarterly evaluations and service plans to Community RN, Resident Care Coordinator and Executive Director.  Corporate RN to review assessment tool in EHR system to allow for improved ability to meet resident needs related to resident specific factors. 3.  ED, LN or Corporate RN to review quarterly evaluations on an ongoing basis. 4.Ed, LN or Corporate RN

2. Resident 5 was admitted to the facility in 10/2021 with diagnoses including dementia and delirium due to known physiological condition. The current service plan, dated 02/23/24, and Temporary Service Plans from 01/08/24 to 03/03/24 were reviewed, and observations of Resident 5 and interviews with staff were completed during the survey. The following was identified: The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas: * Level of assistance required with bathing, dressing, grooming, oral care, toileting, and transfer status; * Conflicting direction for nail care; and * Use of a psychotropic medication. The need to ensure service plans were reflective of  the resident's current needs and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings . 5. Resident 1 was admitted to the memory care in 02/2023 with diagnoses including dementia. Observations, interviews, and review of the 12/17/23 service plan revealed Resident 1's service plan was not reflective of the resident's current needs and preferences and lacked clear direction to staff in the following areas: * Use of glasses; * Mobility, including use of walker; * Weekly outings with family member; * Eating routines; and * Resident-specific emergency evacuation instruction. The need to ensure service plans were reflective of residents' current care needs and preferences and provided clear directions to staff was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. 3. Resident 3 was admitted to the facility in 03/2022 with diagnoses including brain stem stroke syndrome and Alzheimer's disease. The current service plan, dated 02/23/24, and Temporary Service Plans from 12/26/23 to 02/27/24 were reviewed, and observations of Resident 3 and interviews with staff were completed during the survey. The following was identified: The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas: * Level of assistance required with bathing, dining, toileting, and grooming; * Behavior Management Plan; * Emergency evacuation assistance; * Fall mat placement; and * Use of a psychotropic medication. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 01/2020 with diagnoses including dementia and major depressive disorder. The current service plan, dated 02/23/24, and Temporary Service Plans from 01/30/24 to 02/20/24 were reviewed, and observations and interviews with staff and Resident 4 were completed during the survey. The following was identified: The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas: * Ability to use the call system; * Level of assistance required with bathing, dressing, grooming, oral care, toileting, bed mobility, and transfers; * Management of incontinence supplies; * Use of mobility aids; * Emergency evacuation assistance; and * Use of a psychotropic medication. The need to ensure service plans were reflective of  the resident's current needs and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type II diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease. Observations of care on 03/04/24 through 03/07/24, interviews with the resident's family and staff, and review of the current service plan, dated 12/20/23, revealed Resident 2's service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas: * Use of communication board to assist resident with staff interactions; * Incorrect reference to presence of Foley catheter; * Incorrect reference to use of supplemental oxygen for breathing; * Social and leisure activities; * Dietary, nutrition, and hydration management; * Repositioning schedule and measures to prevent skin impairments; * Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * Fall mat placement; * Recent losses; * Instructions for evaluation of weekly behavior management plan; * Instructions for aspiration precautions and interventions while choking; * Instructions on signs and symptoms of hypo- and hyperglycemia to report; * Instructions on weight management; * Instructions on specific changes of condition to report to hospice; * Instructions on proper maintenance of air mattress used for pressure ulcer prevention; and * Instructions on changes in appetite. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. No further information was provided.

260 Service plans 1. Residents 1,2, 3, 4 and 5 have been updated. 2. The consultant will provide training on service plan components and include a service plan checklist to ensure all elements are addressed. Consultants will review newly updated service plans for completeness. Service plan schedule is being implemented to track.   3. Weekly audits of service plans. 4. Administrator and nurse.

3. Resident 10 was admitted to the facility in 09/2021 with diagnoses including Alzheimer's disease, glaucoma, spinal stenosis and osteoarthritis of the knee. Observations, interviews with facility staff and review of the current service plan, dated 06/11/24, and temporary service plan updates were conducted during the survey. The service plan was not reflective of the resident's current needs or lacked clear direction regarding the delivery of services in the following areas: * The resident no longer wore compression stockings; * Instructions were lacking for providing and placing the resident's hearing aides; * Instructions were lacking for setting the resident's room temperature; and * Instructions were lacking for ensuring the resident's desire to sit outside, even in warm temperatures, was honored. The need to ensure Resident 10's service plan was reflective and included adequate instructions for providing care and services was reviewed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health Services Director, RN), Staff 33 (RCC), Staff 37 (Regional Clinical Director), Staff 38 (Senior VP Operations) and Witness 8 (Consultant) on 07/11/24 at 12:35 pm. They acknowledged the findings. 2. Resident 9 moved into the memory care community in 10/2022 with diagnoses including dementia and congestive heart failure. Observations, interviews with the resident's family and facility staff, and review of the current service plan, dated 06/10/24, and temporary service plans were conducted during the survey. The service plan was not reflective of the resident's current needs, lacked clear direction regarding the delivery of services, and/or was not implemented in the following areas: * Sleep preferences, including the use of a recliner; * Oral care assistance and frequency; * Resident preference to have the door to his/her room open during the day; * Nutrition habits, including "special diet" of bacon with breakfast; and * Environmental preferences, including room temperature. The need to ensure the service plan reflected the resident's current needs, provided clear instruction for staff, and were implemented was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 39 (Quality Assurance RN), Witness 2 (Consultant), and Witness 8 (Consultant) on 07/11/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs, provided clear direction to staff regarding the delivery of services and were implemented for 3 of 5 sampled residents (#s 7, 9, and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 moved into the memory care community in 07/2020 with diagnoses including Alzheimer's disease and anxiety disorder. Observations of care on 07/08/24 through 07/10/24, interviews with the resident's family and staff, and review of the current service plan, dated 06/05/24, identified Resident 7's service plan was not reflective of the resident's current status, lacked clear direction for staff and/or was not implemented in the following areas: * Clear instruction for emergency evacuation; * Escorts needed to the dining room with the use of a tilt-in-space wheelchair; * Use of assistive devices and who to report maintenance/safety concerns to (hospital bed, toilet riser, two wheeled walker); * Transfer status (two person verses one person); * Toileting status (two person verses one person); and * Consistently implementing proper diet texture (mechanical soft). Observations during the survey confirmed the resident used a tilt-in-space wheelchair, required staff escorts to the dining room for all meals, and required two-person care for all transfers and toileting needs.   On 07/09/24, during the breakfast meal observation the resident recieved meal assistance from staff and was served toasted bread and approximately one-to-two-inch fresh cut melon. During an interview on 07/09/24 at 9:35 am, Staff 34 and Staff 44 (Dietary Aides) reported "mechanical soft is basically the way that it is cut, like finely chopped. We [the kitchen staff] chop a large bowl of fresh fruit. We bring it to the smaller kitchens and the caregivers put it on the plates. They are supposed to cut it smaller if needed. We also don't prepare the toast for breakfast; the caregivers do that [in the kitchenettes]." During interviews on 07/10/24 with Staff 35 (Care Partner), Staff 42 (Care Partner) and Staff 43 (Care Partner) it was reported Resident 7 required two-person care for transfers, toileting, required assistance with eating and had an order for mechanical soft diet texture. The need to ensure the service plan reflected the resident's current status and condition, provided clear instructions for staff, and was implemented was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings.

1.  Resident 7 Quarterly Service plan was completed on 7/8/24 due to change in condition on 7/8/24.  The following areas were corrected- clear instructions for emergency evacuation, escorts needed to dining room with use of tilt back wheelchair.  Use of assistive device on who to report maintenance safety concerns to, transfer status, toileting status, consistently implementing proper diet texture.  Resident 9 Quarterly service plan was completed on 7/12/24 with corrections made to the following areas-sleep routine including use of recliner, oral care assistance and frequency, resident preference to have door open during the day, nutrition habits including special diet and environmental factors including room temperature.   Resident 10-Quarterly service plan was completed on 7/8/24 due to a change in condition on 7/7/24 to reflect the resident no longer had compression stockings, instructions for hearing aides, instructions for room temperature, instructions for being outside even during extreme warm temperatures. 2.  On 7/24/24 Regional RN provided 2.5 hours of training related to quarterly evaluations and service plans to Community RN, Resident Care Coordinator and Executive Director. Consultants will be reviewing updated service plans. 3.  Corporate RN to review quarterly service plans on an ongoing basis. 4.Corporate RN

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 3 of 5 sampled residents (#s 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to: Resident 3, 4, and 5's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans. During an interview on 03/07/24, Staff 2 (Vice President of Operations) confirmed the facility lacked documented evidence of a Service Planning Team for Residents 3, 4, and 5. On 03/07/24, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 2 and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

For 262: 1. Service plan team meetings are scheduled for residents 3, 4 and 5. 2. A service plan schedule has been developed and service plan team meetings will be scheduled upon service plan updates. The white board is being used to track service plans due and completed. 3. Service plan completion will be reviewed weekly and team meetings scheduled upon completion. Process will be audited monthly in the QI meeting. 4. Administrator.

3. Resident 5 moved into the facility in 10/2021 with diagnoses including dementia, hypertension, and type II diabetes. The resident's current service plan, dated 02/23/24, Temporary Service Plans, and  progress notes dated 12/01/23 through 03/04/24 were reviewed. Observations of the resident and interviews with staff were completed between 03/04/24 and 03/07/24. The resident experienced multiple short-term changes of condition as outlined below: a. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined action or intervention to staff on all shifts, or documented progress at least weekly through resolution for the following short-term changes of condition: * 12/01/23 - Bloody nose; * 12/17/23 - "blood all over [his/her] ... bloody nose"; and * 01/12/24 - Refused all morning medications. b. Temporary service plans were created and monitoring was initiated, but progress was not documented at least weekly through resolution, for the following short-term changes of condition: * 01/08/24 - Change in insulin dose (Levemire); * 01/09/24 - Discontinued insulin (Humalog) and blood sugar level check three times daily; * 01/18/24 - Low blood sugar level and increased agitation; and * 02/01/24 - Discontinued insulin (Levemire). The need to ensure changes of condition were evaluated, actions or interventions were determined and communicated to staff, and residents were monitored per their evaluated care needs, with progress documented at least weekly until resolution, was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia. Review of the 12/05/23 through 03/04/24 progress notes, 12/27/23 service plan, and Temporary Service Plans (TSP's) revealed Resident 1 experienced the following short-term changes of condition: * 12/05/23 - Wound to left calf; * 01/09/24/23 - Resident-to-resident altercation; * 01/21/24 - Medication refusals; * 02/10/24 - Medication refusals; and * 02/18/24 - Blood found in brief. The facility lacked documented evidence actions or interventions were developed and communicated to staff on each shift and changes of condition were monitored, with progress noted at least weekly through resolution, for each of Resident 1's short-term changes of condition. The need to ensure the facility had a system to determine and document what actions or interventions were needed for a resident's short-term changes of condition, ensure actions or interventions were communicated to staff on each shift, and ensure progress was documented at least weekly until the conditions resolved was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. 4. Resident 3 was admitted to the facility in 03/2022 with diagnoses including brain stem stroke syndrome and Alzheimer's disease. The resident's current service plan, dated 02/23/24, Temporary Service Plans, progress notes dated 12/01/23 through 03/03/24, and corresponding incident reports were reviewed. Observations of the resident and interviews with staff were completed between 03/04/24 and 03/07/24. The resident experienced multiple short-term changes of condition as outlined: a. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident and communicated the determined action or intervention to staff on all shifts for the following short-term changes of condition: * 01/10/24 - Non-injury fall; and * 01/30/24 - Non-injury fall. b. There was no documented evidence the facility monitored the following short-term changes of condition, with progress noted at least weekly: * 12/26/23 - Resident tested positive for COVID; * 01/24/24 - Medication dose changes for lorazepam and haloperidol (psychotropic medications); and * 02/16/24 - Medication dose change for warfarin (blood thinner). The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. 5. Resident 4 was admitted to the facility in 01/2020 with diagnoses including dementia and major depressive disorder. The resident's current service plan, dated 02/23/24, Temporary Service Plans,  progress notes dated 12/02/23 through 03/02/24, and corresponding incident reports were reviewed. Observations of the resident and interviews with caregivers were completed between 03/04/24 and 03/07/24. The resident experienced multiple short-term changes of condition as outlined below: a. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined actions or interventions to staff, or documented weekly progress through resolution for the following short-term change of condition: * 01/01/24 - Resident tested positive for COVID. b. b. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident and communicated the determined actions or interventions to staff on all shifts for the following short-term changes of condition: * 01/16/24 - Missed morning medications, increased tiredness; and * 02/16/24 - Return from emergency room. c. There was no documented evidence the following short-term changes of condition were monitored, with progress documented at least weekly through resolution: * 02/09/24 - Extreme confusion; * 02/12/24 - Room change; and * 02/20/24 - Return from hospital due to increased anxiety and agitation. The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed for a significant change of condition, and failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) who experienced changes of condition. Resident 2 experienced ongoing weight loss. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type 2 diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease. Clinical records, including the current service plan, dated 12/20/23, progress notes from 12/05/23 through 03/03/24, and outside provider notes were reviewed, and interviews with facility staff were conducted. a. Facility weight records noted the following: * 10/17/23 - 141.5 pounds; * 12/14/23 - 125.4 pounds; and * 01/02/24 - 124.0 pounds. The resident's MARs indicated the resident was to be weighed monthly on the second day of the month. There were no weights documented in 11/2023, 02/2024, or 03/2024. The facility was asked to get a current weight for the resident during the survey, and the weight was noted as 111.0 pounds on 03/06/24, which was a decrease of 13.0 pounds since the last weight in 01/2024. Resident 2 lost 17.5 pounds, or 12.36% of his/her body weight, in three months (10/17/23 through 01/02/24), resulting in a significant change of condition. Observations of the resident between 03/04/24 and 03/07/24 showed the resident was unable to feed himself/herself once provided food, was observed to be lethargic or asleep for the majority of the time, was not verbally communicative with staff, and did not follow commands. The resident's intake varied, with multiple meals at more than 50%. There was no documented evidence of ongoing monitoring of the resident's weight, and there was no documentation interventions and adjustments were in place to prevent additional weight loss. According to Resident Assessment forms completed in 12/2023 and 01/2024, nursing consultants were aware of the weight loss but did not complete RN assessments and facility did not implement interventions as a result of this awareness. * 12/20/23 - Resident Assessment noted "Resident has lost more than 16 pounds in the last 3 months."; * 01/04/24 - Resident Assessment noted "Resident has lost more than 16 pounds in the last 3 months."; * 01/26/24 - Hospice physician signed order to start "mechanical soft texture diet for ease of swallowing."; * 01/29/24 - Hospice note stated "Patient has had continuing difficulty with chewing/swallowing and pocketing food even after change to mechanical soft texture diet."; and * 01/29/24 - Hospice physician signed order instructing to start resident on pureed texture diet. During meal observations conducted in the resident's room from 03/04/24 through 03/07/24, the following was noted: * 03/04/24 - Lunch tray with a pureed-texture food was delivered to the resident's room, but the resident was not fed; * 03/05/24 - Staff 25 (Care Partner) fed resident breakfast from 9:30 am to 10:16 am after being prompted by the surveyor, and Resident 2 consumed 100%. Lunch was fed by Staff 29 (Care Partner) from 12:30 pm to 1:15 pm, and Resident 2's total intake was 100%; * 03/06/24 - The resident was fed breakfast from 8:45 am to approximately 9:40 am and ate 75%; and * 03/07/24 - The resident was fed breakfast from 9:59 am to approximately 10:45 am. In an interview on 03/06/24, Witness 2 (RN Consultant) indicated she was aware of the weight loss for the resident but had not completed any assessment of the loss. Resident 2 experienced ongoing weight loss from 10/2023 to 03/2024. There was no documented evidence the facility evaluated the resident, referred to the facility nurse, documented the changes, updated the service plan as needed, and monitored weekly. b. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined action or intervention to staff, or documented weekly progress through resolution for the following short-term changes of condition: * 01/04/24 - Progress note stated "Resident has had a change of condition noted related [sic] to a decrease in ... mobility. [S/he] has developed a stage 1 pressure ulcer above [his/her] coccyx."; * 01/22/24 - Hospice note stated "Patient has potential fungal rash noted to peri-area and left armpit causing patient discomfort."; and * 01/22/24 - Hospice physician signed order to start Miconazole 2% powder related "to erythema to the neck, chin, and face also noted to the peri wound of the coccygeal area associated with pruritus and 'fungal-like odor'." The need to ensure the facility evaluated the resident, referred to the facility nurse when necessary, documented the change, and updated the service plan as needed for a significant change of condition, and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 2 (Vice President of Operations) and Witness 2 on 03/07/24. They acknowledged the findings. No further information was provided.

270 Change of Condition 1. Residents 1, 2, 3, 4, and 5 were assessed for changes of condition, and their service plans were updated to reflect current needs and communicate needed interventions. 2. A weight monitoring system was implemented-RCC is coordinating monthly weights in the beginning of the month. Nursing will be reviewing weights routinely to identify and respond to weight changes. Third party notes are being reviewed in the clinical meeting and TSPs initiated for changes. Skin conditions are being tracked on the whiteboard to ensure treatment, monitoring and resolution. Medication refusals will be reviewed daily in the clinical meeting and plans to increase compliance reviewed and revised as needed.   3. Changes of Condition will be monitored daily in the clinical meeting and tracked weekly on the whiteboard. 4. Administrator and nurse.

3. Resident 10 was admitted to the facility in 09/2021 with diagnoses including Alzheimer's disease, glaucoma, spinal stenosis and osteoarthritis of the knee. The resident's record including the current service plan, dated 06/11/24, Temporary Service Plans (TSPs), incident reports and progress notes from 05/06/24 to 07/08/24 were reviewed. Observations were made and interviews were conducted with facility staff. The service plan noted the resident was a high fall risk who had a history of falls, had poor safety awareness and often tried to self-transfer when s/he actually needed two staff to assist with transfers. Fall interventions were for staff to provide safety checks every two hours and to ensure the resident wore non-slip footwear. The facility documented that between 05/09/24 and 07/07/24 the resident had eight falls. One fall resulted in bruising on the left shin and left hand. No injuries were reported for the other falls. For five of the eight falls, the facility was unable to provide documented evidence it determined, documented and communicated to staff what actions or interventions were needed for the resident. For seven of the eight falls, the facility failed to monitor whether the service-planned interventions had been followed prior to the resident's fall, whether the interventions were effective or whether additional or different interventions needed to be implemented. The facility did not implement any new interventions to try to address the repeated falls. The need to ensure the facility determined, documented and communicated to staff what actions or interventions were needed for the resident following a fall and monitored whether the interventions were being followed and were effective or whether additional interventions needed to be developed was reviewed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health Services Director, RN), Staff 33 (RCC), Staff 37 (Regional Clinical Director), Staff 38 (Senior VP Operations), Witness 2 (Consultant) and Witness 8 (Consultant) on 07/10/24 at 1:45 pm and 07/11/24 at 12:35 pm. They acknowledged the findings. 2. Resident 9 moved into the memory care community in 10/2022 with diagnoses including dementia and congestive heart failure. The resident's record including the current service plan, dated 06/10/24, Temporary Service Plans (TSPs), incident reports, and progress notes from 05/08/24 to 07/08/24 were reviewed. Observations were made and interviews were conducted with the resident's family and facility staff. The facility failed to evaluate, determine action or intervention needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following short-term changes of condition: * 04/08/24: Compression socks and elevate legs; * 05/07/24: Wound management; * 05/10/24: Bilateral lower extremity edema; * 05/15/24: New scab on fourth left toe; * 05/15/24: Left wrist red circle; * 05/29/24: New medication for UTI; * 05/29/24: New wound, inferior/lateral multiple small open weeping sores; * 06/01/24: Discontinued medication; * 06/11/24: Missed medication; and * 06/12/24: Resident to resident altercation. The need to ensure the facility had a system to determine and document what actions or interventions were needed for a resident's short-term changes of condition, ensure actions or interventions were communicated to staff on each shift, and monitor at least weekly until resolution was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 39 (Quality Assurance RN), Witness 2 (Consultant), and Witness 8 (Consultant) on 07/11/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, document weekly progress until the condition resolved, and reviewed interventions for effectiveness for 3 of 5 sampled residents (#s 7, 9 and 10) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 moved into the memory care community in 07/2020 with diagnoses including Alzheimer's disease and anxiety disorder. Clinical records, including the current service plan, dated 06/05/24, progress notes from 05/07/24 through 07/08/24, and outside provider notes were reviewed, and interviews with facility staff were conducted. The facility failed to evaluate, determine action or intervention needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following short term changes of condition: * On 05/06/24 - Medication error occurred when the resident was found with two fentanyl patches on his/her body; * On 05/10/24 - Pain and restarting scheduled Tylenol; * On 05/16/24 - "...scattered bruising on the anterior forearm"; * On 05/31/24 - Redness to the breast area and tender to the touch; * On 06/10/24 - Redness to the coccyx area and right upper leg/brief line; * On 06/21/24 - A "healing cut on the RT [right] hand"; * On 07/01/24 - Discontinue polyethylene glycol; * On 07/03/24 and 07/04/24 - Medication errors regarding Fentanyl patches; * On 07/05/24 - Discontinue twice per day Senna; and * On 07/08/24 (during the survey) - The resident presented with a skin tear to the right lower leg/ shin area, bruising to his/her left top of hand and wrist area. S/he also had an approximate two inch by one inch bruise on his/her upper arm, near his/her elbow. The need to ensure the facility had a system to determine and document what actions or interventions were needed for short-term changes of condition, ensure actions or interventions were communicated to staff on each shift, and ensure progress was documented at least weekly until the conditions resolved was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings.

1.  Resident 7 Change in Condition was completed on 7/8/24 due to change in condition on 7/8/24.  All areas were corrected.    Resident 9 Quarterly Evaluation was completed on 7/12/24 with corrections made to all areas. Resident 10 Change in condition was completed on 7/8/24 All areas were corrected. 2. Training provided to RN, RCC and ED related to temporary changes in condition, TSP's, alert charting and monitoring to ensure that actions and interventions are put in place for temporary changes in condition, how to communicate those changes to staff and what actions are necessary and for what length of time, monitoring is in place until change is resolved. To be completed by 8/5/2. All new orders will be reviewed in clinical meeting to ensure TSP's and alert charting started. 3.  Corporate RN to review alert charting and TSPs on weekly basis with RN, ED and RCC via zoom. ED and LN to review daily in clinical meeting. 4.Corporate RN

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed an assessment which documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (# 2) who experienced significant changes of condition related to loss of weight. Resident 2 continued to experience ongoing weight loss. Findings include, but are not limited to: Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type 2 diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease. Clinical records, including the current service plan, dated 12/20/23, MARs from 12/01/23 through 03/04/24, progress notes from 12/05/23 through 03/03/24, and outside provider notes were reviewed, and interviews with facility staff were conducted. According to the resident's MARs, the resident's weight was scheduled to be taken on the second day of each month, and the primary care physician and the facility nurse were to be notified of a five pound or greater weight loss or gain in one month. The following weights were recorded by the facility: * 10/17/23 - 141.5 pounds; * 11/02/23 - no weight recorded; * 12/14/23 - 125.4 pounds; * 01/02/24 - 124.0 pounds; * No weight was recorded in 02/2024; and * 03/06/24 - Resident was weighed per surveyor request and recorded to be 111.0 pounds. The resident experienced a 17.5 pound weight loss, or 12.36% of his/her total body weight, in three months (10/17/23 through 01/02/24). This represented a significant change of condition. The resident experienced an additional significant change of condition with the loss of 14.4 pounds in three months, or 11.48% of his/her total body weight, between 12/14/23 and 03/06/24. Review of the clinical records revealed the following: * A facility Resident Assessment (RA) form was completed in connection with a quarterly service plan update on 12/20/23. The RA form noted "Resident lost more than 16 pounds in the last 3 months. Staff to observe, report, and document any changes in wt gain or wt loss of 5 pounds to the HSD/ED [Health Services Director/ED] or designee and to the provider and family." The RA form was completed and signed by an LPN nursing consultant. There was no documented evidence an RN conducted an assessment which documented findings, resident status, and interventions made as a result of the assessment. * A facility RA form was completed on 01/04/24 in connection with a change of condition assessment related to the resident's "... decreased mobility with the development of a stage 1 pressure ulcer above [his/her] coccyx." The Resident Assessment form was signed by an RN nursing consultant and noted "Resident lost more than 16 pounds in the last 3 months. Staff to observe, report, and document any changes in weight gain or wt loss of 5 pounds to the HSD/ED [Health Services Director/ED] or designee and to the provider and family." The RN acknowledged the previously noted weight loss; however, there was no documented evidence the RN conducted a nursing assessment which included findings, resident status, or interventions made as a result of the assessment. The most recent Service Plan stated resident "can not feed [her/himself]," but did not provide clear instructions to staff on weight and appetite management. Resident 2 was started on a soft mechanical texture diet for ease of swallowing on 01/26/24 per hospice physician signed order. The diet was downgraded to pureed texture diet on 01/29/24 due to "Patient has had continuing difficulty with chewing/swallowing and pocketing food even after change to mechanical soft." During meal observations conducted in the resident's room from 03/04/24 through 03/07/24, the following was noted: * 03/04/24 - Lunch tray was delivered to the resident's room, but the resident was not fed; * 03/05/24 - Staff 25 (Care Partner) fed resident breakfast from 9:30 am to 10:16 am, after being prompted by the surveyor, and Resident 2 consumed 100%. Lunch was fed to the resident by Staff 29 (Care Partner) from 12:30 pm to 1:15 pm, and Resident 2's total intake was 100%; * 03/06/24 - The resident was fed breakfast from 8:45 am to approximately 9:40 am, and ate 50%; and * 03/07/24 - The resident was fed breakfast from 9:59 am to approximately 10:45 am. During an interview on 03/06/24, Staff 13 (Care Partner) stated, "If you really want to feed [the resident] and be patient, s/he can eat 75%. It takes time. If three of us [assigned Care Partners to the unit] [are on duty] . . . it's ok, but if somebody calls-out . . . we can't." The ongoing weight loss and change in diet texture constituted significant changes of condition requiring an RN assessment. There was no documented evidence the facility RN conducted assessments which included documentation of findings, resident status, and interventions made as a result of the assessments, and the resident continued to lose weight. Witness 2 (RN Consultant) confirmed on 03/06/24 the facility was unable to produce the assessments. The need to ensure an RN assessment was completed for residents who experienced a significant change of condition was reviewed with Staff 2 (Vice President of Operations) and Witness 2 on 03/07/24. They acknowledged the findings. No further information was provided.

280 Resident Health Services 5. Resident 2 has been evaluated for significant weight loss and the service plan has been updated with needed interventions. 6. All-staff training is scheduled to include what conditions need to be referred to the RN for significant change of condition. Weights are being monitored monthly and reviewed by the RN for significant changes. 7. Changes of condition will be monitored weekly on the whiteboard. Weights are to be reviewed by the RN monthly. 8. RN and administrator.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 5) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task. During the acuity interview on 03/04/24, the resident was identified to receive insulin injections from staff and s/he was the only resident who received insulin injection. The survey team requested the resident's current MAR and progress notes during the survey on 03/04/24, however, no documentation was provided by the end of the day on 03/04/24. On 03/05/24, at approximately 9:00 am, Witness 3 (RN Consultant) was observed checking the resident's blood sugar level. Witness 3 stated she was going to administer an insulin injection to the resident. On 03/05/24, at approximately 9:43 am, Staff 2 (Vice President of Operations) reported the previous night during an audit, the facility identified two undelegated staff had administered insulin injection to the resident. Therefore, the facility implemented a plan to address the findings. During the survey, 03/05/24 through 03/07/24, Staff 7 and Witness 3 confirmed they would check the resident's blood sugar level and administer insulin injections as ordered. On 03/07/24 at 10:30 am, the delegation task was reviewed with Staff 2 and Witness 2 (RN Consultant), and they acknowledged the findings.

C 282 Delegation 1. RN has assumed responsibility of RN delegation. Delegating RN is knowledgeable of RN delegation rules. 2. The RN is working closely with the community to communicate who is delegated and has a clear delegation supervision schedule. This RN has taken the Role of the Nurse Class for Community Based Care. Consultant has reviewed delegation requirements. 3. The delegation book will be reviewed monthly to ensure compliance. 4. RN

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 3 of 3 sampled residents (#s 2, 4, and 5) who received incontinence care and meal assistance from staff. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 10/2021 with diagnoses including dementia, hypertension, and type II diabetes. Observations and interviews with staff during the survey identified the resident relied on staff for incontinence care needs. On 03/04/24, at approximately 1:40 pm, the surveyor obtained permission from the resident and observed Staff 24 (Care Partner) provide incontinence care for Resident 5. During the observation, Staff 24 wore gloves and failed to change the gloves after wiping fecal matter from Resident 5's perineum. Staff 24 flushed the toilet and touched a clean brief, a shirt, and a pair of pants while wearing the same soiled gloves. The above observation was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24 at 10:30 am. The staff acknowledged that appropriate infection control practices were not followed. 3. Resident 3 was admitted to the facility in 03/2022 with diagnoses including brain stem stroke syndrome and Alzheimer's disease. Observations of the resident and interviews with staff from 03/04/24 through 03/07/24 revealed Resident 3 relied on two staff for incontinence care needs. On 03/05/24 at 9:15 am, Staff 17 (Care Partner) and Staff 18 (Care Partner) provided ADL incontinence care for Resident 3. Staff 17 and 18 donned gloves prior to providing incontinence care. Staff 17 removed the resident's soiled clothing and soiled brief, performed peri care, and then applied barrier cream to the area without doffing soiled gloves, performing hand hygiene, and donning clean gloves. The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type II diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease. During the acuity interview on 03/04/24, Resident 2 was reported to be on hospice, with bedbound status, and on a pureed-texture diet requiring meal assist. During the survey, from 03/04/24 through 03/06/24, surveyor obtained permission and observed the facility staff provide personal care and feeding to Resident 2. Resident was noted to require total care assist from the staff. On multiple instances staff donned gloves without first performing hand hygiene, did not change single-use gloves between tasks, and performed feeding without wearing a protective barrier. The need to establish and maintain effective infection prevention and control protocols was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. No further information was provided.

C 295 Infection Control 1. ED will take infection control specialist training. Staff were counseled on the importance of hand hygiene and changing gloves between clean and dirty tasks. Staff also trained in hand hygiene at mealtimes. 2. All-staff training is scheduled in April to review infection control practices. RCC, nurse and administrator will complete daily rounds ensuring resident care tasks are provided in a fashion that respects infection control practices. Training records will be updated to ensure all staff have taken the Relias infection control training.   3. Daily and monthly. 4. Administrator, RCC and nurse.

2. Most residents ate meals on the 300 unit. Meal service and meal  assistance for several residents was provided by caregivers and the medication technician. During observations of lunch service on 07/09/24 and 07/10/24, the following concerns regarding safe food handling were identified: * On both days, as care staff served the meal items and went from table to table to check on residents, they repeatedly touched residents' wheelchairs, dining chairs, and residents' clothing without then washing their hands before handling another resident's plate or beverage cup. * On 07/10/24, only one of three care givers donned an apron prior to beginning meal service to prevent cross-contamination from the uniforms they wore when providing personal care to residents. These deficiencies increased the risk of the spread of communicable diseases to residents. The need to ensure all facility staff consistently followed safe food handling practices was reviewed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 1 of  3 sampled residents (#7) and multiple unsampled residents who received meal assistance from staff. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 moved into the memory care community in 07/2020 with diagnoses including Alzheimer's disease. Observations of the resident and interviews with staff from 07/08/24 through 07/10/24 identified the resident relied on staff for meal assistance, hydration and snacks throughout the day, and required assistance with incontinent care from caregivers. From 07/08/24 through 07/10/24, Staff 18 (Care Partner), Staff 32 (Health and Wellness Director/RN) and Staff 43 (Care Partner) were observed providing ADL care for multiple residents throughout the survey and would also assist with plating and serving resident meals and drinks from the kitchenette. On 07/09/24 at 9:14 am, Staff 18 was observed sitting between Resident 7 and another unsampled resident providing meal assistance for both residents. Staff 18 was not wearing gloves and an apron or other protective barrier to prevent the potential for cross contamination from their clothing when assisting with meal service. Staff 18 also failed to ensure hand hygiene was performed before assisting another resident with meal assistance. On 07/09/24 at 12:42 pm, Staff 32 failed to ensure a barrier was between the resident and their plain clothing prior to providing meal assistance. Staff 43 took over assisting the resident with his/her meal. Staff 43 failed to wash hands before assisting the resident, failed to don clean gloves and failed to have on an apron or other protective barrier between their clothing and the resident, to prevent potential cross contamination from their clothing. The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings.

1.In service Provided on 7/11/24 and again on 7/18/24 with staff related to infection control during meal service when assisting residents with eating.  Hand Sanitizer provided on tables with residents who need assistance with eating. Reviewed use of aprons when serving meals. Training provided on using hand sanitizer between assisting different residents, touching any items such as w/c tables, etc.     2.  RN, ED, and RCC will provide meal monitoring 7 times weekly and at least once during breakfast, lunch and dinner to ensure appropriate hand hygiene and infection control practices are being consistently followed. 3.  Regional RN will review meal monitoring log weekly via zoom call with RN, ED and RCC. 4. ED, LN and RCC or Corporate RN.

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to: During the re-licensure survey, conducted 03/04/24 through 03/07/24, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C282 - RN Delegation and Teaching; * C302 - Systems: Tracking Control Substances; * C303 - Medication and Treatment Orders; * C310 - Medication Administration; and * C330 - PRN Psychotropic Medications. The need to ensure a safe medication and treatment system was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

C300 Systems: Medications and Treatments 1. See other citations in this section.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#3) who was administered as-needed narcotic medication. Findings include, but are not limited to: Resident 3 was admitted to the facility in 03/2022 with diagnoses including brain stem stroke syndrome and Alzheimer's disease. Resident 3 had a physician order for morphine 0.25 ml by mouth every hour as needed for pain/shortness of breath. Resident 3's 02/01/24 through 03/04/24 Controlled Substance Disposition Logs and MARs were reviewed and revealed the following: Between 02/01/24 and 03/04/2024, there were four occasions when staff signed the medication out in the disposition log; however, the MAR lacked documentation the resident received the PRN medication. Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Witness 2 (RN Consultant) on 03/07/24. No additional information was provided. The need to ensure the facility had a system for tracking controlled substances was discussed with Staff 2 (Vice President of Operations) and Witness 2 on 03/07/24. The findings were acknowledged.

C302 Systems: Tracking Control Substances 1. Staff training done on ensuring MAR and control log are used when signing out controlled substances. 2. A Med-tech meeting scheduled for April to review elements of a safe controlled medication system including documentation, storage, signing out, shift count, discrepancies and reordering. Change of shift count is being observed multiple times per week by nursing and the administrator, and MAR audit is being completed weekly. 3. Daily and weekly. 4. Administrator and nurse.

2. Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia. The resident's 02/01/24 through 03/04/24 MAR and signed physician's orders, dated 12/21/23 were reviewed on 03/06/24. The following was identified: Resident 1 had physician's orders to receive the following medications: * Omeprazole 20 mg (gastroesophageal reflux disease) one capsule daily; * Azo D-Mannos 500 mg (probiotic) two capsules twice daily; * Ursodiol 300 mg (gall stones) one capsule twice daily; * Vitamin B-12 500 mg (supplement) one tablet every morning; and * Atorvastatin 20 mg (cholesterol) one tablet at bedtime.   The medications were not included on the MAR, and the facility lacked documented evidence the medications were administered as prescribed between 12/21/23 and 03/04/24. The need to ensure physician orders were carried out as prescribed was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 5 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type II diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease. Review of Resident 2's current hospice physician orders, dated 12/26/23, and MARs from 01/01/24 through 03/05/24 revealed the following: * The physician order stated, "any medications or treatments prior to this [new] list, which are currently not listed are considered discontinued." The new list did not contain the previously given order to check blood sugar levels twice daily. According to the MARs, staff continued to check blood sugar levels from 01/01/24 through 01/18/24. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. No further information was provided.

C303 Systems: Treatment Orders 1. Resident 1 and 2 orders were reviewed for accuracy to ensure all medications and treatment orders are carried out as prescribed. 2. A third check system is in place to ensure all new orders are carried out as prescribed. Orders will be reviewed daily in the clinical meeting. Routine pharmacy audits are scheduled, and nursing is following up with recommendations. Quarterly physician orders are being sent out to ensure current orders for all medications and treatments. Consultants are providing training at routine med-tech meetings to ensure all med-techs are trained in order processing and administering orders as prescribed.   3. Daily in the clinical Monthly MAR audits by RCC and nursing, quarterly review of physician orders. 4. Administrator and nurse.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 5 sampled residents (# 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 9 moved into the memory care community in 10/2022 with diagnoses including dementia and congestive heart failure. The resident's 05/06/24 through 07/08/24 MAR and signed physician's orders, dated 06/17/24 were reviewed. The following was identified: Resident 9 had a physician's order to receive the following medications: * Vitamin B12 5000 mcg: one tablet, under the tongue, one time a week; and * Nitrofurantoin 100 mg: one capsule by mouth, twice daily, for 10-days. The facility lacked documented evidence the medications were administered as prescribed between 05/06/24 through 07/08/24. On 07/11/24, Staff 37 (Regional Clinical Director) stated she was aware the medications were not administered as prescribed. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37, Staff 38 (Senior Vice President of Operations), Staff 39 (Quality Assurance RN), Witness 2 (Consultant), and Witness 8 (Consultant) on 07/11/24. They acknowledged the findings.

1. Resident 7- Medication incident reports were completed at time incidents were reported , related to Vitamin B12, TSP was in place and alert charting was completed, no adverse outcomes were noted due to increased B12.  Pharmacy interface caused medication to be populated daily instead of weekly and was not fixed on review by previous RCC.  Resident Nitrofurantoin was delivered on 5/26 order was obtained on 5/24.  Medication d/c order was obtained prior to 10 day end date.  Medications were not administered correctly as indicated prior to 6/1/24.  Medication technician training was provided by Regional RN related to 7 rights of medication administration on 5/29/24, 6/5/24, 6/12/24, medication error reporting, alert charting and monitoring for medication errors. 2.  Medications Pending reviews are completed by RN during 3rd check system.  Medication orders are reviewed, verified and entered by RN. Medication Technicians will be trained on 7 rights of medication administration prior to administering medications to residents. 3. Regional RN will review medication incident reports weekly with community RN, ED and RCC via zoom. 4. Corporate RN

2. Resident 12 was admitted to the facility in 08/2016 with diagnoses including hypertension, delusional disorder, and Alzheimer's disease. Resident 12's current facility records and MARs from 10/01/24 to 10/29/24 were reviewed. Resident 12's current facility records included a physician order to "administer polyethylene glycol 17 g by mouth twice daily as needed for constipation." Review of MARs showed the polyethylene glycol was scheduled for administration at 8:00 am and 8:00 pm daily. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 30 (Acting ED), Staff 48 (RCC), and Witness 8 (Consultant) on 10/30/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 2 sampled residents (#s 12 and 13) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 13 moved into the facility in 11/2022 with diagnoses including Alzheimer's disease and vascular dementia. Observation of the resident on 10/30/24 at 9:02 am, revealed Staff 50 (Care Partner) was assisting the resident with breakfast and there was a cup of liquid without a straw observed on the tray. Staff 50 reported it was regular liquid, not thickened liquid. Review of the resident's current order, signed on 07/15/24, showed Resident 13 was prescribed to have "spoon thick thickened liquids." which indicated the facility failed to follow a signed physician order as prescribed. The need to ensure physician orders were followed as prescribed was discussed with Staff 30 (Acting ED) and Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Witness 2 (Consultant 1) and Witness 8 (Consultant 2) on 10/30/24 at 2:38 pm. They acknowledged the findings.

1. Resident #13 has passed since time of survey. Resident #12 physician orders (PO) were updated immediately and communication was made with the physician. A new Diet Order Form was created to better streamline communication from physician to LN to Dining Director. All areas were corrected. 2. PO audits will be a routine standard practice for the community. The first audit will occur on 11/26/2024 by the community LN. On 11/12/2024, a full 3-way audit (MAR to cart to order) was completed by PharMerica. All orders will go through the third check system and PharMerica is providing additional training to medication staff on order processing and elements of a safe medication system. All diet orders have been reviewed and there is an improved system in place to communicate diet changes. 3. POs will be reviewed with physicians on a quarterly basis, pharmacy audits will occur quarterly, and POs will be reviewed by the community LN on a weekly basis and as needed. 4. The Regional Clinical Specialist with the Regional Operations Director will ensure all actions are completed and monitored moving forward.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and included resident-specific parameters and instructions for PRN medications for 2 of 5 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia. The resident's 02/01/24 through 03/04/24 MARs and physician's orders were reviewed and identified the following: * Bisacodyl 10 mg suppository, insert one daily PRN (for constipation); * Milk of Magnesia 400 mg, take two tablespoons daily PRN (for constipation); * Polyethylene glycol, dissolve one packet in eight ounces liquid and take by mouth daily PRN (for constipation); and * Senna 8.6 mg, take one tablet twice daily PRN (for constipation). The PRN medications for bowel care lacked resident-specific parameters for the sequential order of use. The requirement for MARs to be accurate, including resident-specific parameters for PRN medications, was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type II diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease. Resident 2's MARs from 12/01/23 through 03/04/24 and physician orders, signed 12/26/23, were reviewed. According to the MARs, the resident's weight was to be taken on the second day of each month; however, the MARs for 02/2024 and 03/2024 did not contain any recorded weights or initials of the person taking the weights. The need to ensure MARs were accurate was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. No further information was provided.

310 Systems: Medication Administration 1. Residents 1 and 2 MAR updated to include indications of use and diagnoses. The weight system is also being updated to ensure MAR reflects weight monitoring. 2. Indications and diagnoses are being updated when orders third checked by nursing. Full MAR audit to be completed to ensure indications and diagnoses are added to MAR. Monthly MAR review is also being initiated to ensure all indications of use and diagnoses are present.   3. Several times per week in the clinical meeting and monthly.   4. Administrator and nurse.

2. Resident 3 was admitted to the facility in 03/2022 with diagnoses including brain stem stroke syndrome and Alzheimer's disease. A review of the resident's 02/01/24 to 03/04/24 MARs revealed s/he was prescribed the following PRN psychotropic medications: * Lorazepam 0.5 mg, 1 tablet by mouth every two hours as needed for "anxiety"; and * Haloperidol 0.25 ml by mouth every two hours as needed for "hallucination/agitation/nausea/vomiting." There were no written, resident-specific parameters on the MAR for the PRN psychotropic medications to indicate symptoms for which they would be administered. In an interview on 03/06/24 at 1:45 pm, Staff 10 (MT) reviewed the electronic MAR and confirmed there were no resident-specific parameters for the resident's PRN psychotropic medications. The need to include resident-specific parameters on the MAR for all PRN psychotropic medications was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN medications that were given to treat a resident's behavior had written, resident-specific parameters for 2 of 2 sampled residents (#s 3 and 4) who were prescribed psychotropic medications. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 01/2020 with diagnoses including dementia and major depressive disorder. A review of the resident's 02/01/24 to 03/04/24 MARs revealed s/he was prescribed PRN psychotropic medication: * Olanzapine 5 mg, 1 tablet twice daily as needed for delirium. There were no written, resident-specific parameters on the MAR for the Olanzapine to indicate symptoms for which it would be administered. In an interview on 03/06/24, Staff 23 (Care Partner) reviewed the electronic MAR and confirmed there were no resident-specific parameters for the resident's PRN psychotropic medication. The need to include resident-specific parameters on the MAR for all PRN psychotropic medications was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

330 Systems: Psychotropic Medication 1. Residents 3 and 4 MARs were updated to include resident-specific signs and symptoms of use and non-pharmaceutical interventions to try prior. 2. A full MAR audit is being completed to identify and update all parameters for PRN psychotropics. MAR will be reviewed monthly to ensure all parameters are in place. 3. Several times per week in the clinical meeting and monthly during scheduled MAR review. 4. Administrator and nurse.

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with restraining qualities had a thorough assessment completed by the facility registered nurse, a physical therapist, or an occupational therapist prior to use which included documentation of less restrictive alternatives evaluated prior to use for 1 of 1 sampled resident (#2) who had side rails on the bed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type II diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease. During the acuity interview on 03/04/24, staff facility stated there were no side rails being used by any current residents. Upon observation on 03/04/24, Resident 2's hospital bed was observed to have two half-length side rails in the up position. An entry in the resident's Progress Notes, dated 12/13/23 at 1:06 am by Staff 28 (Clinical Director), recorded, "Assessment for side rails completed." However, there was no documented evidence the facility registered nurse, a physical therapist, or occupational therapist conducted a thorough assessment or that other, less restrictive alternatives were evaluated prior to the use of the device. Witness 2 (RN Consultant) confirmed on 03/07/24 there was no assessment available. During a phone interview on 03/07/24, Witness 1 (Family Member) confirmed the family was aware of the side rail use and had agreed to it as a fall prevention measure. The need to ensure the facility registered nurse, a physical therapist, or an occupational therapist had conducted a thorough assessment and other, less restrictive alternatives were evaluated prior to the use of a supportive device with restraining qualities was reviewed with Staff 2 (Vice President of Operations) and Witness 2 on 03/07/24. They acknowledged the findings. No further information was provided.

340 Restraints and Supportive Devices 1. Resident 2 side rail has been thoroughly assessed by the RN and the service plan updated to reflect use. 2. Room audit was performed to identify other assistive devices and assessments completed with service plan updates.   3. Devices will be assessed quarterly and with significant change of condition that may impact safe use of the device.   4. RN and administrator.

Based on interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) included information for 1 of 5 residents (#4) to inform the generated staffing plan and failed to update the ABST for each resident at least quarterly. Findings include, but are not limited to: Review of the facility's ABST on 03/05/24 found Resident 4's ADL information was located in the archive record of the tool and, therefore, did not inform the generated staffing plan, which potentially created inaccurate staffing calculations. In addition, the review revealed 15 of the 33 current facility resident's ABST records were last updated in 2022 and not at least quarterly as required. During a 03/06/24 interview, Staff 2 (Vice President of Operations) acknowledged the ABST was not reflective of the ADL's needs for Resident 4 and had not been updated at least quarterly for multiple residents. The need to ensure the ABST included information for each resident to inform the generated staffing plan and was updated for each resident at least quarterly was discussed with Witness 2 (RN Consultant) on 03/07/24. She acknowledged the findings.

361 Acuity-Based Staffing Tool 1. The Acuity Based Staffing Tool is being updated to reflect current residents' needs. 2. Consultants have provided training on completing the ABST with each admission and scheduled service plan update and with significant change of condition. 3. Weekly with service plan updates and monthly with QI meetings. 4. Administrator.

Based on observation, interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) to accurately reflect the time needed to care for 2 of 5 residents (#s 7 and 9) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 moved into the memory care community in 10/2022 with diagnoses including dementia and congestive heart failure. The resident's ABST, service plan available to staff dated 06/10/24, and active Temporary Service Plans (TSP) were reviewed, interviews with the resident's family and facility staff were conducted, and observations of the resident were made. The resident's ABST failed to capture the amount of staff time needed to provide care in the following areas: * Personal hygiene including oral care; * Assistance with bowel and bladder management; and * Time spent providing treatments. The need to ensure the ABST addressed the amount of staff time needed to provide care for the resident was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 39 (Quality Assurance RN), Witness 8 (Consultant), and Witness 2 (Consultant) on 07/11/24. They acknowledged the findings. 2. Resident 7 moved into the memory care community in 07/2020 with diagnoses including Alzheimer's disease. During the acuity interview on 07/08/24 staff reported the resident required two staff to transfer, required full ADL care including one-on-one meal assistance and was on hospice. Review of the facility's ABST for Resident 7 identified the facility failed to convert evaluated care needs into accurate staff hours used to generate the facility's staffing plan in the following areas: * Time spent supervising, cueing or supporting while eating; * Time spent for bowel and bladder management; * Time spent repositioning in bed or chair; * Time spent transferring in or out of bed or chair; and * Additional care and services for two person care needs. The need to ensure the facility's ABST converted evaluated care needs into accurate staff hours used to generate the facility's staffing plan was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings.

1. Resident 7- ABST was updated 7/10/24.  ABST tool is reflective of average time spent performing ADL's by staff, not extreme instances. Resident 9-ABST was updated 7/11/24 2.  ABST training to be provided by Regional Operations Director by 8/5/24.  Education will include how to explain use of ABST tool and reasoning for staffing. 3. Monthly by Regional Operations Team 4. ED and Regional Operations Team.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month, and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: Fire drill and fire and life safety training records for the last six months were requested at the entrance conference on 03/04/24. Documentation was provided for last three months, not six months as requested. The documentation was reviewed during the survey and the following deficiencies were identified: 1. The facility failed to conduct fire drills every other month; therefore, documentation was lacking in the following required areas: * Date and time of fire drill; * Location of simulated fire origin; * The escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; * The number of occupants evacuated; and * Evidence alternate routes were used during the fire drills. During the interview on 03/06/34, Staff 6 (Maintenance Director) reported he was new to the facility and confirmed he had not conducted fire drills for last 3 months. 2. Fire and life safety instruction was not consistently provided to staff on alternate months. On 03/07/24 at 10:30 am, Staff 2 (Vice Present of Operations) confirmed there was no additional documentation related to fire and life safety prior to 12/2023. The requirements regarding fire drills and fire and life safety instruction for staff on alternating months was reviewed with Staff 2 and Witness 2 (RN Consultant) on 03/07/24. The staff acknowledged the findings.

420 Fire, Life and Safety: Safety 1. Approved fire drill form has been provided that meets the required elements of a fire drill. Staff were provided with training on fire procedures and policies. 2. A schedule has been implemented for ongoing drills and an agenda developed for ongoing staff training on fire, life and safety procedures. 3. Monthly during fire drills and reviewed in the QI meeting. 4. Administrator and maintenance.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to: Fire and life safety records were requested and reviewed with Staff 6 (Maintenance Director) on 03/06/24, and the following deficiencies were identified: * There was no documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission; and * There was no documented evidence of fire and life safety training provided to residents at least annually. The need to ensure residents received fire and life safety training within 24 hours of admission and at least annually was discussed with Staff 6 on 03/06/24 and Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. No additional information was provided.

422 Fire and Life Safety: Training for Residents 1. Residents will have received their annual training of Life Safety Program including fire drills and evacuation plan.   2. New residents will receive the fire drill and evacuation plan within 24hrs of move in. All residents will receive fire and life safety (including fire drills and evacuation) annual retraining with any updates. Those residents needing special assistance will be identified and the care plans will reflect evacuation plans for each resident.   3. Monthly QA meeting will review compliance of the Fire and Life Safety Program.   4. Maintenance Director/ED

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: During the re-licensure survey, conducted 03/04/24 through 03/07/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective, based on the number and severity of citations. Refer to C150, C160, C200, C231, C361, C420, and C422.

Referral--Non Healthcare Rules   Phone interview with Tood Whitehead, Administrator on 05/02/24 at 4:15 pm. The facility origanally submitted aPOC for the referral tag Z142 the POC did not address the non health care RALF rules cited in the survey. After discussion with Todd, he gave permission to have the original POC for Z142 removed  and "refer to POC for cited areas" submitted in its place. Change was made by Mo Mills, Surveyor on 05/02/24. .

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 231, C 295, and C 361.

Refer to C 231, 295 and 361

Based on interview and record review, it was determined the facility failed to ensure staff completed all required annual training for 3 of 4 veteran direct care staff (#s 11, 12, and 26) whose training records were reviewed. Findings include, but are not limited to: A review of staff training records on 03/05/24 with Staff 4 (Business Office Manager) revealed the following: Staff 11 (Care Partner), hired 01/11/22, Staff 12 (Care Partner), hired 07/22/20, and Staff 26 (Care Partner), hired 09/24/20, had not completed the required 16 hours of annual training related to provision of care for residents, including six hours related to dementia care. The need to ensure all veteran staff completed 16 hours of annual training was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

Z155 - Staff training: 1. Staff members audited during survey have been given their training assignments. 2. A full training audit will be completed to ensure that staff have completed the required 16 hours of annual training related to provision of care for residents, including six hours related to dementia care. New hires will complete all training required and training audit forms will be utilized. 3. Staff training records will be audited monthly in the QI meeting. 4. Administrator and BOM

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: During  the re-licensure survey, conducted 03/04/24 through 03/07/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations. Refer to C252, C260, C262, C270, C280, C282, C295, C300, C302, C303, C310 , C330, and C340.

Referral--Healthcare Rules Phone interview with Tood Whithead Administrator on 05/02/24 at 4:15 pm. The facility origanally submitted aPOC for the referral tag Z162 the POC did not address the non health care RALF rules cited in the survey. After discussion with Todd, he gave permission to have the original POC for Z162 removed  and "refer to POC for cited areas submitted in its place. Change was made by Mo Mills, Surveyor on 05/02/24. Z164 - Individualized activity plan 1. The Residents social identified during survey as being out of compliance, will be reviewed, parameters obtained, and individualized activity plans created.   2. An audit of all residents will be conducted, and social profiles updated as needed.   3. Social profiles will be completed for all residents upon move-in, upon any change of condition, and annually thereafter. These profiles will be routinely reviewed by the LED, ED, and HSD to ensure accuracy before service plan meetings with families. 4. LED/Designee/ED

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, C 260, C 270 and C 303.

Refer to C 252, 260, 270 and 303

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

Refer to C303.

Based on observation, interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C231, C252, C260, C270, C295, C303, C361, Z142 and Z162.

1.  Implement Plan of Correction- The ABST has been updated for resident 7 and 9. 2. ED, RN, Regional RN Regional Operations Team will follow POC to Correct Deficiencies-ABST will be reviewed to ensure it reflects all current resident needs.  Moving forward, the ABST will be reviewed as required upon admission, within 30 days quarterly and with change of condition. 3. ED, RN, Regional RN, Regional Operations Team will review Quarterly to ensure continued compliance. 4.  Corporate RN and Operations Team.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 303.

Refer to C303.

Concerns were identified in the following areas and the facility was provided with technical assistance: H1515: OAR 411-004-0020(2)(b) Physical Setting: Individual Accessible . (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual.

The findings of the re-licensure survey, conducted 03/04/24 through 03/07/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to the Home & Community-Based Services rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 03/07/24, conducted 07/08/24 through 07/11/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL:   activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC: Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day

The findings of the second re-visit to the relicensure survey of 03/07/24, conducted 10/29/24 through 10/30/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 03/07/24, conducted 12/19/24, 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 observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the licensee failed to ensure adequate administrative oversight of facility operations including supervision and training of staff, which posed a risk to the safety of residents. Findings include, but are not limited to: Administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of confirmed allegations. 1. On 12/08/23 Situations were identified which constituted an immediate plan of correction to residents' health and safety in the following areas: OAR 411-054-0025 (1)(b) Facility Administration; Operation OAR 411-054-0025 (4) Reasonable Precautions OAR 411-0054-0027 (1) Resident Rights and Protections OAR 411-054-0040 (1-2) Change of Condition and Monitoring OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching OAR 411-054-0055 (1)(a) Systems: Medications and Treatments OAR 411-054-0055 (1)(f-h) Systems: Tracking Control Substances OAR 411-054-0070 (1)(g) and (6)(G) Staffing Requirements and Training OAR 411-057-0160 (2)(c) Nutrition and Hydration 2. Monitoring visits conducted by the Licensing Complaint Unit on 12/09/23 and 12/10/23 indicated the facility had not implanted all changes requested in the immediate plan of correction requested on 12/08/23. 3. Refer to the allegations in the report. It was determined the facility failed to ensure adequate administrative oversight of facility operations including supervision and training of staff Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. This placed residents at risk and constituted an immediate threat to residents' health and safety. Findings include, but are not limited to: 1. During a Licensing Complaint Unit (LCU) site investigation, multiple licensing violations were identified that placed the health, safety and welfare of residents living in the facility at risk: OAR 411-054-0025 (1)(b) Facility Administration; Operation OAR 411-0054-0027 (1) Resident Rights and Protections OAR 411-054-0040 (1-2) Change of Condition and Monitoring OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching OAR 411-054-0055 (1)(a) Systems: Medications and Treatments OAR 411-054-0055 (1)(f-h) Systems: Tracking Control Substances OAR 411-054-0070 (1)(g) and (6)(G) Staffing Requirements and Training OAR 411-057-0160 (2)(c) Nutrition and Hydration On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the immediate jeopardy was abated. 2. During LCU facility monitoring visits, conducted on 12/09/23 and 12/10/23, issues were identified that continued to threaten the health, safety, or welfare of residents. These included, but were not limited to: * On 12/09/23 Resident 2, a COVID positive resident, lacked any documented evidence staff had been instructed on the specific care needs of the resident. Witness 20 (Agency Staff) stated there was a PPE bin outside of the resident's room but was unsure if "there is anything else they are supposed to do for [him/her] related to COVID." * On 12/10/23 at approximately 11:30 am, Resident 7 was observed sitting on his/her soiled bed "half" dressed, with his/her feet on the floor. Resident's room smelled heavily of fecal matter. Brown smeared matter was visible on the exterior of the resident's toilet bowl. * On 12/10/23 observations of Resident 15, conducted between 11:04 am and 2:00 pm, indicated Staff did not cue resident to go to the dining room for lunch, offer a meal tray, or provide any care services. * On 12/10/23 observations of Resident 3, showed no staff entered the resident's room between 11:55 am and 1:55 pm. Resident 3 was not provided or assisted with lunch or offered fluids. It was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23. Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on observation, interview, and record review, it was confirmed the facility failed to treat residents with dignity and respect, provide a safe and homelike environment, and ensure residents were free of neglect. Multiple residents were left soiled for hours and were not provided basic care. Findings include, but are not limited to: On 12/08/23 at approximately 5:50 am, the night shift caregiver for the hall where Residents 2, 7, and 38 resided was observed to be wearing flip flops, sitting on a couch on his/her phone, and not wearing a mask despite two positive Covid cases in the facility. On 12/08/23, at approximately 8:30 am, Residents 2, 7, and 38 were observed to have been left wet and soiled by night shift. During an interview on 12/08/23, Staff 21 stated the following: - S/he had changed and cleaned the room of Resident 38 after s/he had been left wet and soiled by night shift; and - S/he had changed Resident 2 but had not changed his/her wet bedding because Resident 2 required a two person assist due to weakness from Covid. After the interview with Staff 21, feces were observed smeared across the floor of Resident 38's apartment. On 12/08/23, the stench of feces was observed in the hallway outside of Resident 7's room at approximately 10:30 am. A binder labeled "200 Hall ADL Binder" indicated  "Every MT and care staff must initial off on every shift, every day as part of the caregiving routine. If you do not initial, you did not complete the task." Every page in the binder for every resident was blank. During interview on 12/04/23 through 12/08/23, staff members stated the following: - Staff 7 stated "it's not infrequent to find people wet and soiled;" - Staff 8 (MT) stated Resident 39 was often left wet and soiled; - Staff 14 (MT stated the morning of 12/05/23 Residents 17, 19, and 40 had been found left wet and soiled by the night shift; - Staff 15 (MT) stated s/he finds wet and soiled residents "all the time" when s/he starts his/her shift. S/he stated she usually finds residents 17 and 20 wet and soiled; - Staff 10 (MT) stated Residents 7, 22, and 42 were regularly left wet and soiled; - Staff 17 (Activities) stated "there's never enough hands," s/he had observed residents left soiled for long periods of time and confirmed "it happens with a handful of residents" on a regular basis; and - Staff 18 (MT) stated Resident's 19 and 20 were frequently left wet and soiled. During an interview on 12/08/23, Witness 14 (Outside Agency RN) stated the following: - S/he had found Resident 20 and his/her bedding "abnormally" soiled that morning; and - His/her agency staff "regularly" found Resident 20 soiled and wet, including the previous three days. During an interview on 12/08/23, Witness 16 (Family Member) stated his/her biggest complaint was showers, and that Resident 4 was supposed to be showered on Tuesdays, Thursdays, and Saturdays. The last two Saturdays Resident 4 had not received his/her shower. S/he further stated it had been an issue "for months" and at one point the facility had told Witness 16 "didn't have enough staff to give [Resident 4] a shower." Resident 4's service plan, dated 10/16/23, indicated s/he was to be showered twice a week on Mondays and Fridays. It also indicated "Staff to encourage [Resident 4] to shower three times a week." A sign posted on the refrigerator in the 300 wing indicated Resident 4 was to receive showers on Saturday nights. A review of "End of Shift Reports" for 11/2023 and 12/2023 indicated the following regarding Resident 4: - There was no indication Resident 4 was showered from 11/08/23 through 11/17/23; - There was no indication Resident 4 was showered from 11/22/23 through 12/02/23. Notes on 11/25/23 indicated "Could not do shower as swing was not available to cover hall;" and - No indication Resident 4 was showered from 12/04/23 through 12/08/23. Notes on 12/05/23 indicated "water is cold water heater not working" and on 12/07/23 "resident not showered. (No hot water)." The facility's failure to provide basic care, treat residents with dignity and respect, and provide a safe and homelike environment resulted in neglect. On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated. Monitoring visits conducted by the Licensing Complaint Unit on 12/09/23 and 12/10/23 indicated the facility had not implanted all changes requested in the immediate plan of correction requested on 12/08/23. During a monitoring visit on 12/11/23 at approximately 10:38am, Resident 7 was observed by LCU in his/her room naked from the waist down. Resident 7's brief was soiled and on the floor. No care staff was observed assisting Resident 7 until approximately 12:14pm. Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23. Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to determine or document actions or interventions, communicate actions or interventions to staff, monitor a residents condition, or evaluate the resident and refer to the facility RN for 2 of 2 sampled residents (#s 2 and 12) who experienced a change of condition. Resident 12 experienced a significant decline in health when routine medication was not administered. Findings include, but are not limited to: 1. On 12/08/23, Witness 1 (Family Member), approached the LCU team during their site visit. S/he stated s/he was very concerned and had "never seen a decline" for Resident 12 before. A review of Resident 12's record indicated the following: Hospice provider notes, dated 12/05/23, indicated Resident 12 had experienced a decline in his/her health status, to include increased shortness of breath, wheezing, bilateral lower-extremity edema, and anxiety. On 12/06/23, "Outside Agency Documentation" left by the hospice RN indicated "worsening of [heart failure], adjusted furosemide (may be [routine] meds not given)."  "...increase Furosemide to 40mg for 3 days..." There was no documented evidence the facility had reviewed the documentation left by hospice on 12/05/23 or 12/06/23. During an interview on 12/08/23, Witness 6 (Family Member) stated s/he was "worried" about Resident 12 because s/he did not seem to be him/herself, that s/he was usually "alert" and "cheerful," and that Resident 12's "demeanor and breathing had changed drastically." On 12/08/23 at approximately 10:30 am Resident 12 was observed to be slouched over in his/her wheelchair, visibly short of breath, somnolent, and barely verbal, unable to answer questions. On 12/08/23 Staff 3 (LPN) stated s/he was aware Resident 12 "was out of baseline," however s/he had received his/her "first dose [of Furosemide] this morning." There was no documented evidence Resident 12 had received any Furosemide on the morning 12/08/23. MAR documentation indicated the medication was "pending refill." On 12/08/23, outside provider notes from hospice indicated "Worsening [bilateral lower extremity] edema and now up thighs, thready radial pulses, irregular [heart rate]. Cardiac meds had not been administered by staff since 11/20...continues to have significant [bilateral lower extremity] edema, dyspnea at rest, audible congestion in lungs, denies pain, furosemide increase (ordered 12/6) started today 12/8." A review of Resident 12's MAR, for the period 11/01/23 through 12/08/23, indicated the following routine medications had not been administered from 11/19/23 through 12/08/23: * Atorvastatin (cholesterol)  80mg; * Furosemide (diuretic) 20mg; * Losartan (high blood pressure) 25mg; and * Metoprolol (heart medication) 12.5mg. The following was documented in the Resident's progress notes: * 11/20/23, staff documented, "many medications we had run out of for [Resident 12]" and "they will be here on the next delivery later today." * On 12/06/23, staff documented Resident 12's pharmacy had been contacted to refill Furosemide, however there were no refills left, and hospice was called to send refills to pharmacy. * On 12/07/23 staff documented hospice had been called to confirm the new furosemide order and the hospice nurse confirmed [Resident 12] was to take 40mg furosemide for three days starting 12/08/23. There was no documented evidence the facility had monitored the resident's condition between 11/19/23 and 12/08/23 related to the missed doses of medication, had determined actions or interventions and communicated those actions or interventions to staff when the resident's health declined, or had evaluated the resident and referred to the facility RN when the resident's health continued to decline. 2. During an interview on 12/07/23 Staff 12 (MT) confirmed Resident 2 had tested positive for Covid. On 12/08/23, Staff 21 (CG) stated Resident 2 "felt very hot to the touch" and was "very weak" and required two staff assist. Staff 21 was not aware of any updated care or services to be provided to Resident 2. On 12/08/23 Staff 3 (LPN) stated the residents on COVID protocols "should be" on two-hour checks and confirmed Resident 2's service plan had not been updated to reflect increased care needs. On 12/08/23 Staff 12 stated "Resident 2 [not scheduled for two-hour checks] as far as I know." There was no documented evidence the facility determined actions or interventions, communicated the actions or interventions to staff, or monitored Resident 2. On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated. It was determined the facility failed to document actions or interventions, communicate actions or interventions to staff, monitor a residents condition, or evaluate residents and refer to the facility RN when a resident experienced a change of condition. Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23. Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on interview and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 1). Resident 1 was put at risk when unlicensed and undelegated staff were improperly trained or delegated. Findings include, but are not limited to: 1. A review of Resident 1's delegation records and MARs indicated the following: On 12/04/23 Staff 30 (MT) documented Resident 1's CBG reading was 289 mg/dl. The MAR instructed staff to administer 5 units of Humulog Kwikpen (insulin) if Resident 1's CBG was greater than 200. There was no documented evidence indicating the insulin had or had not been administered as prescribed. There was also no documented evidence Staff 30 (MT) had been delegated to administer insulin for Resident 1. 2. An RN delegation record, dated 11/25/23, signed by Staff 28 (RN) indicated Staff 10 (MT) had been delegated to administer insulin to Resident 1. During interviews on 12/05/23 and 12/07/23, Staff 10 confirmed Staff 28 had not observed Staff 10 administer insulin. Staff 10 further stated Staff 28 could not have observed Staff 10 administer insulin on 11/25/23 because Resident 1's CBG reading was below 200. Resident 1's recorded CBG on 11/25/23 was 116. MAR notes by Staff 10 indicated  "outside parameters." Resident 1's 11/01/23 through 12/11/23 MAR indicated Staff 10 had administered Resident 1's insulin on 12/01/23, 12/02/23 and 12/09/23. On 12/01/23 Resident 1's CBG was documented as 319, and on 12/02/23 the CBG was documented as 309. Staff 10 (MT) administered 5 units of Humulog Kwikpen (insulin) to Resident 1 on both dates. On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated. It was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23. Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, and an interview on 12/13/23, it was confirmed the facility failed to ensure adequate professional oversight of the medication and treatment administration system, carry out medication orders as prescribed, and keep an accurate Medication Administration Record (MAR) for 18 of 18 sampled residents (#s 1, 2, 5, 6, 8, 9, 12, 14, 15, 18, 21, 24, 29, 31, 32, 34, 35, 36). Resident 12 experienced a decline in health when routine medications were not administered as prescribed. 1) On 12/08/23, Witness 1 (Family Member), approached the LCU team during their site visit. S/he stated s/he was very concerned and had "never seen a decline"  for Resident 12 before. A review of Resident 12's record indicated the following: Hospice provider notes, dated 12/05/23, indicated Resident 12 had experienced a decline in his/her health status, to include increased shortness of breath, wheezing, bilateral lower-extremity edema, and anxiety. On 12/06/23,  "Outside Agency Documentation"  left by the hospice RN indicated  "worsening of [heart failure], adjusted furosemide (may be [routine] meds not given)."   "...increase Furosemide to 40mg for 3 days ..." During an interview on 12/08/23, Witness 6 (Family Member) stated s/he was "worried" about Resident 12 because s/he did not seem to be him/herself, that s/he was usually "alert"  and  "cheerful,"  and that Resident 12's "demeanor and breathing had changed drastically." On 12/08/23 at approximately 10:30 am Resident 12 was observed to be slouched over in his/her wheelchair, visibly short of breath, somnolent, and barely verbal, unable to answer questions. On 12/08/23 Staff 3 (LPN) stated s/he was aware Resident 12  "was out of baseline,"  however s/he had received his/her "first dose [of Furosemide] this morning."  There was no documented evidence Resident 12 had received any Furosemide on the morning 12/08/23. MAR documentation indicated the medication was "pending refill." On 12/08/23, outside provider notes from hospice indicated "Worsening [bilateral lower extremity] edema and now up thighs, thready radial pulses, irregular [heart rate]. Cardiac meds had not been administered by staff since 11/20  ... continues to have significant [bilateral lower extremity] edema, dyspnea at rest, audible congestion in lungs, denies pain, furosemide increase (ordered 12/6) started today 12/8." Resident 12's MAR, dated 11/01/23 through 12/08/23, indicated the following: - 11/19/23 through 11/23/23 Atorvastatin 80mg, Furosemide 20mg, Losartan 25mg, Metoprolol 12.5mg, not administered, pending refill; - 11/24/23 all four medications, not administered, refused, when medication was not available; - 11/25/23 all four medications, not available; - 11/26/23 all four medications, not administered, pending refill; - 11/27/23 all four medications, administered,when medication was not available ; - 11/28/23 all four medications, not administered, pending refill; The following was documented in the Resident's progress notes: * 11/20/23, staff documented, "many medications we had run out of for [Resident 12]" and "they will be here on the next delivery later today." * On 12/06/23, staff documented Resident 12's pharmacy had been contacted to refill Furosemide, however there were no refills left, and hospice was called to send refills to pharmacy. The facility's failure to administer medications as prescribed led to a decline in Resident 12's health and placed the resident at risk for further decline. On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated. 2) A review of Resident 1's physician orders, dated 11/01/23 through 11/30/23, indicated the following: *A physician order, dated 11/15/23, indicated Resident 1's Jardiance (antidiabetic) was to be increased from 10mg to 25mg beginning 11/15/23. There was no documented evidence the increased dose had been administered until 11/21/23. *A physician order dated 11/17/23, indicated Resident 1was to continue 100mcg Levothyroxine (thyroid agent). Resident 1's MAR, indicated the following: * Resident 1 received 88mcg Levothyroxine and 100mcg Levothyroxine on 11/10/23 and 11/11/23; *Levothyroxine 100mg was not administered November 12th and 13th, notes indicated  " do not have correct strength dose " ; and *11/15/23 Levothyroxine not administered; notes indicated  " med tech walked out" . 3) Resident 2's, MAR, dated 12/01/23 through 12/13/23, indicated the following: *Missed doses of Amlodipine (blood pressure) on 12/07/23 through 12/09/23. Notes indicated  "medication unavailable "or "pending refill" ; and *No documented evidence 8:00 pm medications had been administered on 12/11/23. 4) A review of Resident 5's MAR, dated 11/01/23 through 11/30/23, indicated the following: *On 11/07/23, Levothyroxine (thyroid) was not administered, notes indicated  "pending refill"; *There was no documented evidence Resident 5 received Levothyroxine on 11/02/23 or 11/10/23; *On 11/28/23, 2:00 pm dose of Morphine ER 15mg had not been administered. Staff documented "med not passed by previous shift"; and *There was no documented evidence Resident 5 received his/her Morphine ER at 9:00 pm on 11/29/23 and 11/30/23. 5) A review of Resident 6's physician orders and 11/01/23 through 11/30/23 MAR indicated the following: *A physician order dated 11/03/23, indicated a decrease in quetiapine (psychotropic) from 100mg to 50mg; *Between 11/04/23 and11/06/23 the resident was administered 100mg quetiapine; and *There was no documented evidence Resident 6 received quetiapine on 11/07/23. 6) A review of Resident 8's MAR, dated 11/01/23 through 12/18/23, indicated the following: *Lidocaine 5% (pain reliever) had a  "start date"  of 10/11/23; *There were thirty five instances where Lidocaine had not been administered with MAR notes indicating "pending refill;",  "refused" when medication was not available,  "unavailable", or  "discontinued." *There were 17 instances where Lidocaine was marked as administered, in between the instances where the medication had been noted as "refused",   "unavailable", or  "discontinued." *Four instances where Resident 8 was not administered Acetamin (pain reliever). Staff documented  "Other: Cannot find. Looked through entire cart,"  "Other: Day shift", "Other: Morning dose not administered," and "Med not available-not in pharmacy formulary"; *Three instances where Resident 8 was not administered Carbamazepine 100mg/5ml (for behaviors). Staff documented  "pending refill,"  "Other: Staffing issue, morning pass too late to administer before last dose, "  and "Other: Unable to locate meds; " *Twenty-eight instances where Venlafaxine ER 150mg (anti-depressant) had not been administered. Staff documented, "pending refill," "Other: Cannot find in cart,"  and "Other: Cannot find will order,". There were several instances where staff documented the medication had been administered and/or refused when the medication had not been available. *Eighteen missed doses of Cephalexin 500mg (antibiotic). Staff documented " pending refill, "  "Other: No more cards," "Other: Could not find,"  " not available, "  "Other: 7 days over," "Other: Cannot locate; "  and "Med not available-not in pharmacy formulary"; *Three instances where Quetiapine 50mg (psychotropic) was not administered, notes indicated  " pending refill "  and  " other: reordering; "  and *At least one missed dose of Divalproex 125mg (anticonvulsant) at 8am, Briviact 10mg (anticonvulsant), Atorvastatin 80mg (cholesterol medication), Doxycycline Monohydrate (antibiotic) Lisinopril 40mg (blood pressure medication, and Buspirone 5mg (psychotropic medication). Notes indicated  " pending refill, "  "Other: Staffing issue, morning pass too late to administer before last dose, "  "Not available, "  "Med not available-not in pharmacy formulary, "  and "Med not available - backorder." 7) A review of Resident 9's MAR, dated 11/01/23 through 12/07/23, indicated the following: *Fifteen instances where Resident 9's Oxycodone IR 5mg (pain reliever) was not administered. Notes indicated  "pending refill," "Other: Med not passed by previous shift," "Not available, "  and "Other: Resident stated doctor wanted her to stop taking medication;" *Four instances where Resident 9's daily vitals were not taken. Notes indicated "No MT here at the time,"  "Other: Med not passed by previous shift,"  or there were no notes. *Two instances where Cephalexin 500mg (antibiotic) was not administered, notes indicated "No MT here at the time" and "pending refill." *Four instances where Mirtazapine 15mg (for dementia) was not administered, notes indicated  " pending refill; " *One missed dose of Propanolol 10mg (anxiety medication). Notes indicated "Other: Med not passed by previous shift " ; and *One missed dose of Acetaminophen 325mg (for fracture). Notes indicated "Not available." 8) Resident 14's clinical record was reviewed and indicated: *Physician orders for Resident 14, dated 11/16/13, instructed the facility to discontinue routine dose of Lorazepam and change his/her diet to mechanical soft. There was no documented evidence the order had been implemented until 11/22/23, when a temporary service plan was put in place.   A review of Resident 14 ' s MAR, dated 11/01/23 through 11/30/23, indicated: *Resident 14 had not received any doses of Lorazepam between 11/01/23 and 11/20/23 when staff were instructed to discontinue the medication. *There were eight occurrences where Resident 14 did not receive Levetiraceta Sol (anticonvulsant). Notes indicated  "Not available,"  "New RX needed-MD Faxed"  "Pending refill"  "Other: Med tech walked out;" *On 11/15/23, the following am medications were not administered: Acetaminophen 500mg (scoliosis), Amlodipine 2.5mg (blood pressure), Levetiraceta Sol, and Metoprolol (blood pressure). Notes indicated  " Other: Med tech walked out " ; 9) A review of Resident 15's physician orders and 09/01/23 through 11/30/23 MAR's indicated the following: *A 09/08/23 physician order instructed staff to " Start Clonazepam 1 whole tablet (0.5mg) twice a day for agitation. Discontinue all prior clonazepam orders and remove them from MAR. " The MAR, dated 09/01/23 through 09/30/23, indicated: *Clonazepam orders had been entered nine different times on the MAR; *On 09/11/23, the MAR indicated Resident 15 was administered Clonazepam three times, instead of the twice daily ordered; *There was no indication Resident 15 received Clonazepam on 09/15/23. *Physician orders, dated 11/03/23, indicated Resident 15's Donepezil 10mg was to be discontinued, and Memantine 10mg dose (Alzheimer medication) discontinued.  Memantine 5mg was to start on 11/07/23. Documentation on the MAR indicated Resident 15 was administered Donepezil on 11/04/23 and 11/05/23, after it had been discontinued. *Seven missed doses of Memantine 5mg, notes indicated  " Other: Do not have this med in new dose strength,"  " Other: We do not have new dose strength,"  " Med not available - Backorder"; *On 11/15/23, MAR indicated Resident 15's routine am medications had not been administered, which included Risperidone 0.5mg (psychotropic) Citalopram 20mg (psychotropic), Clonazepam 0.5mg (for agitation);and Memantine 5mg. Notes indicated  "Other: Med Tech walked out."   *A physician order, dated 11/07/23, indicated Resident 15 was prescribed Haloperidol 1mg" take 1 tablet by mouth every 4 hours as needed for agitation or nausea and/or vomiting." An "End of Shift Report"  dated 11/23/23 indicated Resident 15 had vomited prior to dinner, had not eaten, and MT was notified. There was no documented evidence Resident 15 had been administered Haloperidol as prescribed. 10) A review of Resident 18's MARs, dated 11/01/23 through 11/30/23 indicated the following: *Resident 18 ' s blood pressure had not been taken on 11/14/23. Staff documented "Pending refill"; *11/14/23 9:00 am routine dose of Amlodipine was not administered. Notes indicated  "Pending refill" ; *Atorvastatin 10mg at 9:00 am dose had not been administered on 11/04/23 through 11/06/23, and on 11/14/23. Staff documented "Pending refill " ; *9:00 am dose of Lisinopril 30mg and Metoprolol Succ ER 50mg  had not been administered on 11/14/23. Notes indicated  "Pending refill" and . *No monthly weight was recorded during the month of November 2023. 11) A review Resident 21's clinical records indicated the following: *On 12/01/23 the hospice RN documented Resident 21 had not been administered routine Seroquel and Omeprazole for a "period of time " and confirmed with a facility MT "no supply was available"  The hospice RN also documented " As pt has gone sometime (>2 wks?) w/o Seroquel, new orders will be updated. Please call us - if refills are not arriving from Pharmerica." * A Medication Incident Report, dated 11/30/23, indicated Resident 21 had been administered the "wrong dose" of Quetiapine Fumarate 50mg (psychotropic). (The prescribed dose was 12.5mg, twice daily at 9:00 am and 6:00 pm). -Staff 3 (LPN) asked Staff 10 (MT) how s/he was administering the 12.5mg tabs. Staff 10 stated s/he was  " cutting the 50mg tablets in half and then cutting the [halves] into half. " The medication was not scored to be broken into quarters. *Resident 21's 09/01/23 through 09/30/23 MAR indicated: -Four instances of Cyclobenzaprine 10mg (prescribed for pain) not being administered. Notes indicated  " Med not available - backorder "  and  " Pending refill;"  and * Residents 21's 10/01/23 through 10/31/23 MAR indicated: -One instance of Allopurinol 100mg (for osteoporosis) not being administered. Notes indicated  " Med not available - backorder " ; -One instance of SMZ/TMP 800mg/160mg (anti-infective agent) not being administered. Notes indicated  " Other: Cannot find " ; and -One instance of Quetiapine 50mg not being administered. Notes indicated  " Pending refill. " * Resident 21's 11/01/23 through 11/30/23 MAR indicated: -Eight instances of Omeprazole 20mg (gout agent) not administered. Notes indicated  " Pending refill; " -Seven instances of Quetiapine 50mg not administered. Notes indicated  " Pending refill,"   "Not available,"  "Med not available - backorder;"  and -Ten instances of Quetiapine 25mg (psychotropic medication prescribed for distressing paranoia) not administered. Notes indicated  "Not available" and  "Pending refill." 12) A review of Resident 24's clinical records indicated: *A physician order from June 2023 regarding Warfarin (anticoagulant) dosages indicated Resident 24 was to receive one 5mg tablet on 06/12/23. There was no documented evidence Warfarin was administered on 06/12/23. *Resident 24's 06/01/23 through 06/30/23 MAR indicated 3 missed doses of Sertraline (for depression) 25mg on 06/28/23, 06/29/23, and 06/30/23. Notes indicated  "Pending refill." A review of Resident 24's 08/01/23 through 08/31/23 MAR indicated: *Warfarin 2.5mg was to be administered three times a week on Tues, Thurs, & Sat effective 08/07/23 through 08/21/23. There was no documented evidence Warfarin 2.5mg was administered on 08/15/23; *Warfarin 2.5mg was to be administered in addition to the 5mg dose given the morning of 08/28/23. There was no documented evidence the dose had been administered. *Resident 24 ' s INR (International Normalized Ratio) was to be completed on 08/14/23. There was no documented evidence the INR had been completed. *On 08/24/23, 08/26/23 and 08/29/23, Warfarin 5mg had not been administered. Notes indicated  "Pending refill." During an interview on 12/04/23, Witness 1 (Family Member) stated the following: *The facility had once double dosed Resident 24 with Warfarin in October 2022; *The facility had once not given Resident 24's Warfarin to him her for four days in a row around the same time; *The facility had been unable to get Resident 24's medications right, and "screwed it up so many times we had to take [Resident 24] off Warfarin." 13) Resident 29's clinical records indicate the following: Resident 29's MAR, dated 08/01/23 through 08/31/23, indicated: *Two instances of Memantine 10mg not given, notes indicated pending refill; *Two instances of Pantoprazole 40mg not given, notes indicated pending refill. Resident 29's MAR, dated 10/01/23 through 10/31/23, indicated: *Three instances of Morphine 20mg not given, notes indicated  " other: one bottle empty, second bottle contaminated "  and  " resident difficult to wake during lunch; " *Two instances Pantoprazole not given, notes indicated pending refill; *Two instances Acetaminophen not given, notes indicated pending refill; *Four instances Senna 8.6mg tab not given, notes indicated pending refill; *10/14/23-10/16/23 Sertraline 100mg not given, notes indicated pending refill; *10/17/23 Sertraline 100mg not given, notes indicated refused (when the facility was out of the medication); and *10/18/23 through 10/30/23 Sertraline 100mg not given, notes indicated pending refill. Resident 29's MAR, dated 11/01/23 through 11/31/23, indicated the following: *Ten instances of Senna 8.6mg not given, notes indicated pending refill *Seven instances of Sertraline 100mg not given, notes indicated pending refill *15 instances of Acetaminophen 500mg not administered; *Five instances where it was not indicated whether or not Resident 29 had received Levothyroxine 125mcg with no notes; *All 9:00 am medications on 11/15/23 indicated as not given: staff walked out; *Two instances of donepezil 10mg not administered, notes indicated pending refill and "cannot find". Resident 29's MAR, dated 12/01/23 through 12/11/23, indicated the following: *Five instances where there was no documented evidence Resident 29 had received Levothyroxine 125mcg; *Pantoprazole 40 mg not given 12/07/23 through 12/10/23, notes indicated pending refill or unavailable; *Sertraline 100mg not given 12/09/23 and 12/10/23, notes indicated pending refill; *2 instances there was no documented evidence Resident 29 had received his/her regularly scheduled Morphine; Progress notes for Resident 29, dated 12/11/23, indicated the following: *Late entry for 12/09/23; *"Reason for visit: comfort check, see if morphine orders have been started;" *"Identified concerns and recommended actions taken to resolve: Morphine 20mg/ml by mouth every 4 hours in addition to PRN order for MS. Ordered on November 22nd, still has not been [implemented]. Please start ASAP resent to  ... facility & fax on 12/09". There was no documented evidence Resident 29's increase in Morphine had been implemented until 12/11/23. 14) Resident 31 ' s MAR, dated 08/01/23 through 08/31/23 indicated the following: *Seven instances of quetiapine 25mg not given, notes indicated pending refill; and *Two instances of metoprolol 25mg not given, notes indicated pending refill. 15) Resident 32's MAR, dated 08/01/23 through 08/31/23, intructed staff to weigh Resident 32 every two weeks for weight loss. On 08/15/23 Resident 32 was not weighed, notes indicated  "unable to obtain." 16) Resident 34 ' s MAR dated 11/01/23 through 11/30/23 indicated Eucerin Oring LOT Healing (topical agent) marked as pending refill 11/06/23 and 11/07/23, then "refused" until it was marked "unable to safely swallow" on 11/21/23. 17) Clinical records for Resident 36 indicated: *A physician order dated 11/17/23, Donepezil (for dementia) to be increased to 10mg from 5mg. *There was no documented evidence Resident 36 received Donepezil 10mg until 12/01/23. 18) During an interview on 12/04/23, Staff 9 (Activities) former Resident Care Coordinator, stated the facility protocol for processing medication orders was as follows: *The facility received a physician order; *The physician order was then faxed to the pharmacy; *The order was then put into MT's "first check box", and MT would ensure pharmacy populated the medication onto the MAR so the medication could be administered; *Once the medication was "profiled" on the MAR, the RCC would ensure the MAR matched the physician order; and *The RN would then conduct "third checks" to ensure the medication on hand matched the order and the MAR. Staff 9 further stated s/he had "found a bunch of orders" and had begun processing them. The facility had been behind on orders for a while because an old RCC was putting orders in his/her desk and not completing the second checks. Staff 9 confirmed Resident 15 had several medications pending refill that had not been refilled and Resident 27's Olanzapine had been discontinued by a physician order, but had not been discontinued on his/her MAR. 19) Staff, witnesses, and outside providers stated the following during interviews conducted during the site visit: On12/04/23, Staff 7 (CG) stated s/he had been asked by a med tech to pass medication to a resident with no supervision or training. On 12/05/23, Staff 8 (Med Tech) stated the following: - Residents miss medications because the facility is out of stock; - Med techs do "first checks" for physician orders by reviewing the orders and seeing if they're in the system, then moving them to "second checks". S/he further stated the medications have to go through all three checks before med techs can administer the medication. - "Half the time we have the order and not the meds;" - "I've seen [staff] mark meds as given when we were out of stock;" - S/he had seen meds marked as refused without an attempt to administer medications; - There had been a time when medications received from the pharmacy had been misplaced and staff had to search the building to locate them; - S/he had seen an employee give a resident another resident's medication when the first resident was out of stock on a medication; and - S/he had been called in on 11/15/23 at 10:30 am to cover a shift because both morning med techs had left. No residents in the 100 or 200 halls received am medication that day. On 12/05/23, Staff 14 (Med Tech) stated the following: - A "couple of weeks ago" the facility had run out of CBG test strips. An employee had brought more in at the end of Staff 14's shift. - S/he has found medications in the wrong drawer; On 12/05/23, Staff 3 (LPN) stated s/he was behind on processing physician orders, and had about 40 to process. On 12/07/23, Staff 15 (Med Tech) stated the following: - S/he had observed med techs popping pills into their bare hands; - S/he was told by management "we could take meds for other residents if it was the same dose, [management] told me that when I first started"; - Med techs would mark medications as "not found" when the medications were available and "given" when they were not available; - A couple med techs "will only try to give meds once to difficult residents then give meds to a [caregiver] and leave;" and - S/he had finished the 9 am med pass "a little past 10" in the 300 hall and "later" in the 400 hall. On12/07/23, Staff 18 (Med Tech) stated the following: - Medications were marked as administered when they were not because the facility was out of stock; - There were medications that would have dates to pop the pills out of the card, such as antibiotics, and s/he would come back from his/her weekend and find the pills un-popped; - There were around 70 physician orders pending review; - "We were just told Tuesday to approve orders;" - "I figured out how to [discontinue] orders but I can't approve;" - If medications were not approved, they could not be administered; and - One time the housekeeper put "all the meds in random spots and we couldn't find them." On 12/07/23 Staff 10 (Med Tech) stated s/he had seen a medication card for Ibuprofen with the resident's name ripped off in the med cart. S/he further stated s/he had cut an unscored medication in order to administer the correct dose to Resident 15. On 12/08/23, Witness 14 (Hospice RN) stated the following: - His/her biggest challenge over the last six months was orders being given to the facility and big delays in their implementation. Med techs had told her they had to wait for approval before enacting changes; - Resident 16's diet requirements had been changed from mechanical soft to puree on 10/04/23, and the change had not been made until 10/11/23; - There had been a huge delay in starting Resident 20 on his/her Tizanidine; and - The facility had not notified him/her of medication errors for Resident 20. On 12/13/23, Witness 17 (Hospice Compliance Specialist) stated the following: - His/her hospice agency had 13 primary care patients at the facility, including two patients on hospice; - The hospice agency was sending a care provider on a daily basis because of ongoing concerns with the facility; - Resident 25 had not received coumadin in August and September; - Resident 25's personal care provider (PCP) had tried to get ahold of the facility for about month; - Resident 25 was admitted to the hospital on 09/12/23 with an INR of 1; - Upon Resident 25's return to the facility on 09/14/23, the facility had called the pharmacy asking how to acquire INR test strips; - Resident 25 had been receiving a hypertensive despite a hold order; - The facility had started an order for Risperidone for Resident 36 on 11/08/23. Resident 36's hospice nurse and PCP did not know where the order had originated from; - The hospice agency had discovered the order for Risperidone was from November 2022; - The facility discontinued the order on 12/05/23; - On 11/07/23, the hospice agency's nurse manager submitted a refill for sertraline for Resident 29; - Resident 29 was not administered sertraline for seven days; - Resident 29's order for morphine was changed 11/22/23, the facility did not make the change until 12/07/23; - Resident 19 had missed doses of Warfarin multiple times in September 2023 and October 2023, including from 09/20/23 through 09/27/23; It was determined the facility failed to ensure adequate professional oversight of the medication and treatment administration system, carry out medication orders as prescribed, and keep an accurate Medication Administration Record (MAR) . Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23. Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on interview and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to have a system in place for accurately tracking controlled substances administered by the facility, for 9 of 9 sampled residents (8, 10, 15, 18, 20, 28, 30, 32, 35, and 42) whose MARs, Controlled Substance medications and Controlled Substance Drug Disposition logs were reviewed. The lack of a system in place for tracking and storing of controlled substances put residents at risk of potential harm related to misuse. 1. During an interview on 12/05/23, Staff 14 (MT) stated it was facility policy for the outgoing and incoming med techs to count the narcotics on hand together during shift change, and note counts had been verified in the narcotic disposition log. A review of a facility narcotic disposition log for September 2023 indicated 20 instances where only one staff member had signed the log, or the log was unsigned. A review of a facility narcotic disposition log for October 2023 indicated 41 instances where only one staff member had signed the log, or the log was unsigned. 2. During an interview on 12/05/23, Staff 18 (MT) stated the previous facility RN had destroyed expired narcotics or narcotics for residents who no longer lived in the facility, but had not documented the destruction, so the narcotics log was "messed up." On 12/05/23 Resident 8's Briviact (anti convulsant) was observed to have approximately 100ml. The narcotic disposition log indicated there was 25ml. It was also observed that Resident 8 had two medication cards for Briviact in pill form. Medication had been popped for administration from both cards. On 12/05/23 Resident 18 was observed to have Lorazepam 0.5mg in his/her section of the medication cart that had expired on 11/03/23. On 12/05/23 two bottles of Resident 35's liquid Lorazepam were observed in the facility's medication refrigerator. Resident 35 no longer resided at the facility. The facility's narcotic disposition log indicated that as of 08/29/23 at 5 pm there was a remaining quantity of 27.25ml Lorazepam remaining. The narcotics log did not indicate the strength of Lorazepam. As of 09/09/23 there were 23.5ml of Lorazepam 2mg/ml remaining. During an interview on 12/07/23 Staff 10 (MT) stated Resident 42 had passed away "two to three months ago." Narcotics log for Resident 42 indicated the following: - Staff were to "apply 1 patch [of Fentanyl 12/mcg]  ... every 72 hours for pain." - Resident 42 received a patch on 08/05/23 at 8:00 am, again on 08/06/23 at 10:30, and again on 08/08/23 at 10:00 am. Notes on 08/08/23 indicated  "gave 1 day ahead?" - Resident 42 received Fentanyl on 08/11/23 and then did not receive it again until 08/15/23. - Directions for Resident 42's Morphine 20mg/ml were "take 0.25ml (5mg) PO/sublingual every 2hrs PRN for pain/shortness of breath." - On 07/21/23 at 9:30 am there were 28.25ml of Morphine remaining. The next time it was marked as administered on 07/27/23 there was a remaining amount of 27ml. There were no notes accounting for the four doses missing. - On 07/31/23 there was 25.75ml of Morphine remaining, on 08/03/23, the next time Morphine was administered, there was 25.25ml remaining. - As of 05/01/23 at 4pm there was 28.5ml of Morphine 20mg remaining for Resident 42. There was no Morphine observed for Resident 42 in the medication cart, there was no documented evidence Resident 42's Morphine had been destroyed. A medication disposition record, dated 12/05/23 and signed by Staff 3 (LPN) and Staff 9 (Activites), indicated the facility had destroyed 22ml of Morphine and 1 patch of Fentanyl for Resident 42 on 10/31/23. Staff 3 had not been working in the facility on 10/31/23. A medication disposition record, dated 12/05/23 and signed by Staff 3 (LPN) and Staff 9 (Activites), indicated the facility had destroyed Resident 32's Morphine and Ativan on 10/31/23. Staff 3 had not been working in the facility on 10/31/23. A medication disposition record dated 12/05/23 indicated Hydrocodone had been destroyed. The resident's name listed on the record had the first name of one resident and the last name of another resident. A medication disposition record dated 12/05/23 indicated the facility had destroyed a quantity of "3" of an "unknown" medication for Resident 15. A medication disposition record dated 12/08/23 for Resident 15 indicated the facility had destroyed one tab of Clonazepam 0.5mg. The record was not signed by anyone. A medication disposition record for Resident 10 indicated his/her quetiapine had been destroyed. There was no date on the document. The facility's narcotic disposition log indicated there were 14 remaining tabs of Hydrocodone 5-325 for Resident 28 as of 12/10/22. The following page of the narcotics log indicated 30 remaining tabs of Hydrocodone 5-325 for Resident 28 under a different prescription number. There was no documented evidence Resident 28's Hydrocodone had been destroyed. There was not observed to be any narcotics for Resident 28 in the medication cart. On 12/07/23 a Bupenorphrine patch for Resident 30 was observed loose and unlocked in the medication cart. Resident 30 no longer resided at the facility. During an interview on 12/08/23 Staff 2 (Regional Director of Health Services) stated an unlabeled bottle of morphine had been discovered during a facility self-audit of the med cart. During an interview on 12/08/23, Witness 14 (Hospice RN) stated Resident 20 should not have received his/her morphine on 12/04/23 through 12/06/23 because there was no label on his/her morphine. The facility's failure to have a system in place for accurately tracking controlled substances administered by the facility placed multiple residents at risk. On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated. Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2, Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to provide adequate staff to meet the scheduled and unscheduled needs of residents for 11 of 11 sampled residents (#s 2, 7, 17, 19, 20, 22, 33, 38, 39, 40, and 42). Resident 2 was observed laying in soiled sheets. Resident 7 was observed to be left wet and soiled for an extended period of time. Resident 38's room was observed to be left covered in fecal matter. Findings include, but are not limited to: The facility census on 12/04/23 was 46 residents, 10 of whom were on hospice and approximately five to seven residents who were two person assists, including at least one two person assist in each of the four halls. The facility's posted staffing plan indicated: - Two med techs and six caregivers for day and swing shifts; and - One med tech and four caregivers for night shift. On 12/04/23, 12/05/23, 12/07/23, and 12/08/23, during the day shift, it was observed the facility had four caregivers, one assigned to each of the four halls, and one "float." The facility had two med techs, one assigned to the 100 and 200 halls, and one assigned to the 300 and 400 halls. On 12/04/23, 12/05/23, 12/07/23, and 12/08/23, during the swing shift, it was observed the facility had four caregivers, one assigned to each of the four halls, and one "float." The facility had two med techs, one assigned to the 100 and 200 halls and one assigned to the 300 and 400 halls. During an interview on 12/04/23, Staff 8 (MT) stated the following: - Staffing was "awful", staff wouldn't show up for work, and the facility was constantly understaffed; - "No one really pays attention to what residents are doing"; and - Resident 39 was regularly found wet and soiled. In an interview on 12/04/23, Staff 6 (CG) stated the following: - There "should" be two caregivers per hall; - The other caregiver scheduled to work with Staff 6 was covering breaks in another hall; - There have been times when Staff 6 had to work alone in a hall; - On 11/30/23 Staff 6 was the float for all four halls; - There were three two person assists in the 200 hall. During an interview on 12/04/23, Staff 7 (CG) stated the following: - Over the last month or two the facility had "frequently" been understaffed; - On 10/29/23 residents in one of the halls had been left alone from 6:00 am until approximately 8:45 am because the previous shift had left without waiting for the day shift to show up, the day shift had called out, and no one on the floor had been notified. - Residents were regularly left wet and soiled. Time cards dated 10/29/23 indicated three caregivers and one med tech worked the day shift. During an interview on 12/04/23, Staff 16 (CG) stated s/he was still in training on his/her second day, and that s/he was alone in the 300 hall while his/her trainer was on lunch. During an interview on 12/04/23, Witness 1 (Family Member) stated "I've been here at all times and there are rarely people [in the 300 wing]". S/he further stated s/he had hired a personal caregiver from an outside agency to provide care to her family member in the facility because staffing was so inconsistent. During an interview on 12/05/23, Staff 14 (Med Tech) stated the following: - Staffing was "poor"; - The facility typically had enough staff for one caregiver per hall with one float. - There had been a day when both morning med techs had called out and Staff 14 had been assigned to work as a caregiver that day. S/he was asked by management to act as a med tech; and - The morning of 12/05/23 Resident's 17, 19, and 40 had been found wet and soiled. On 12/05/23, Witness 12 (Family Member) stated she had concerns about staffing and "constant turnover". During an interview on 12/05/23, Witness 14 (Outside Agency RN) stated s/he has seen a "lack of staffing" over the last two years, and has had caregivers share that concern. In hall 400 she was aware of at least one two person assist and had observed caregivers were frequently working by themselves. During an interview on 12/07/23, Staff 15 (MT) stated staffing has "fluctuated a lot,"  that one week there had been four walk outs, and yesterday a staff member had walked out. S/he further stated she finds wet and soiled residents "all the time" when s/he starts her shift. S/he stated she usually finds residents 17 and 20 wet and soiled. During an interview on 12/07/23 Staff 10 (MT) stated the following: - New staff would come in one or two days then stop coming in; - Staff 10's understanding was there should be two caregivers per hall and two floats. Recently there had been one caregiver per hall and one float; and - Residents 7, 22, and 42 were regularly left wet and soiled. During an interview on 12/07/23, Staff 25 (CG) was the only caregiver in the 100 hall and stated s/he was aware of one two-person assist. During an interview on 12/07/23, Staff 17 (Activities) stated "there's never enough hands," s/he had observed residents left soiled for long periods of time and confirmed "it happens with a handful of residents" on a regular basis. S/he also stated during group activities, residents would often soil themselves, and Staff 17 would need to leave the activity with the resident to find an available staff to provide care. During an interview on 12/07/23, Staff 18 stated the following: - The facility regularly "...had four staff working"; - Resident's 19 and 20 were frequently left wet and soiled, as well as another unsampled resident who no longer lived at the facility; and - Staff 18 stated residents being left wet and soiled was a "staffing issue." During an interview on 12/08/23, Witness 14 (Outside Agency RN) stated the following: - S/he had found Resident 20 and his/her bedding "abnormally" soiled that morning; and - His/her agency staff "regularly" found Resident 20 soiled and wet, including the previous three days. On 12/08/23, at approximately 6:00 am, Staff 21 (CG) stated s/he had changed Resident 2 but had not changed his/her wet sheets. Resident 2 required a two-person assist due to increased weakness after contracting COVID, and there was not another caregiver available to assist Staff 21. Staff 21 further stated s/he didn't know how many two person assists there were but "most of the men" required two person assists. On 12/08/23, Staff 21 stated Resident 38 had been left naked and covered in feces from the night shift and s/he was cleaning him/her up. The LCU team observed Resident 38's floor to be covered in smeared fecal matter after Staff 21 exited the room. The facility's failure to provide adequate direct care staff resulted in multiple residents being left wet and soiled for extended periods of time. On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated. It was determined the facility failed to provide adequate staff to meet the scheduled and unscheduled needs of residents. Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23. Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to ensure direct care staff had demonstrated satisfactory performance in any duty they were assigned prior to performing work duties independently, for 5 of 5 sampled staff (#s 6, 8, 10, 16 and 18). Residents' care needs were put at risk related to lack of training. Findings include, but are not limited to: On 12/05/23 CS requested training documents for Staff 6 (CG), 16 (CG), 8 (MT), 10 (MT), and 18 (MT). The facility was unable to provide documented evidence Staff 6, 8 and 16 had completed competencies. Documented competencies for Staff 10 and 18 were incomplete. All five sampled staff were observed providing direct care to residents, including med techs administering medication. During an interview on 12/05/23, Staff 9 (Activities) stated s/he had been the RCC and confirmed training documents for 6, 8, 10 and 16 were either incomplete or missing. Staff 9 further stated the facility process of demonstrating competencies for direct care staff included a competency checklist and confirmed staff should not be providing care unsupervised until they had completed the required training. During an interview on 12/04/23, Staff 8 (MT) stated s/he never filled out a competency checklist. During an interview on 12/05/23, Staff 16 stated it was his/her second day, his/her trainer had gone to lunch, and she would be alone in the hall for half an hour. S/he further stated that orientation had been "four hours of videos [and the] girl with me slept through them." During an interview on 12/05/23, Staff 3 (LPN) stated caregivers received five days of training, and that 12/06/23 was to be Staff 16's final day of training. During an interview on 12/05/23, Staff 14 (MT) stated that recently "we've had trainees training trainees." Staff 14 further stated when s/he first started, the facility had designated trainers and now they don't. During an interview on 12/07/23, Staff 15 (MT) stated the two people training him/her got Covid and s/he had to pass meds by his/herself on his/her third day. During an interview on 12/07/23, Staff 12 (MT) stated s/he had been a med tech for one month and had only been trained "two times" and then "they put me on a cart by myself" because the facility was "short staffed." Staff 12 further stated "If I have questions, I ask questions. If I'm not sure, I don't do it." The facilities failure to ensure direct care staff had demonstrated competency prior to performing work duties resulted in multiple staff being unaware of resident care needs and multiple medication errors. On 12/08/23 at 12:31 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated. It was determined the facility failed to ensure direct care staff had demonstrated satisfactory performance in any duty they were assigned prior to performing work duties independently. Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23. Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to develop an individualized nutrition plan based on the resident's needs for 1 of 1 sampled resident (# 3). Resident 3 experienced a decline in health when s/he was not hydrated or fed. Findings include, but are not limited to: On 12/08/23, at approximately 6:00 am, Resident 3 was observed lying in bed with dry, cracked lips. There was no water available bedside for Resident 3. A review of Resident 3's most recent service plan, dated 11/22/23, indicated Resident 3 was unable to feed him/herself, required one staff member to assist him/her, indicated s/he "enjoys all three meals" and "doesn't really have any foods [s/he] dislikes." The facility was unable to provide an individualized hydration plan for Resident 3 which included how frequently staff were to provide meal assistance or assist resident with hydration. During an interview on 12/08/23 Staff 21 (CG) stated Resident 3 had not been able to eat recently due to build up of plaque and "stuff" in her mouth. Staff 21 also stated the facility's process for tracking resident meals was to circle "y" or "n" (yes or no) for breakfast, lunch, and dinner on the " Meal Attendance Tracking Log". Instructions on the "Meal Attendance Tracking Log" indicated "if ANY meal is not attended, please explain: why, when resident was checked on, how, and BY WHOM." Resident 3's "Meal Attendance Tracking Logs," dated 11/18/23 through 12/07/23, indicated the following: - Eighteen instances where staff failed to document if meals were provided; - Four instances where staff circled "n" and provided no notes; - On 11/29/23 staff circled "n" and notes indicated [Resident 3] "can't eat" for two meals; and - On 12/02/23 nothing was circled, comments indicated "asleep". During an interview on 12/07/23, Staff 3 (LPN) stated it was facility policy to weigh residents once a month between the 1st and 4th of the month. A review of Resident 3's recorded weights indicated the following: - 07/18/23, 156lbs; - 10/17/23, 141.5lbs; and - 12/14/23, 125.4lbs. The facility was unable to provide the requested weights for Resident 3 for June, August, September, or November 2023. The facility's failure to provide staff with an individualized nutrition plan based on Resident 3's needs resulted in Resident 3 missing multiple meals, a lack of hydration, and weight loss. On 12/08/23 at 12:02 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 6:00 pm and the situation was abated. On 12/10/23, during an LCU monitoring visit, no staff members were observed feeding Resident 3 lunch or providing water to Resident 3 between 11:39 pm and 2:10 pm. It was determined the facility failed to develop an individualized nutrition plans based on resident's needs. Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23. Plan of correction: On 12/08/23 facility was requested by the Department to put an immediate plan of correction in place.

Based on interview and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23, and 12/11/23 it was confirmed the facility failed to properly investigate and immediately notify the local Department office of multiple instances in which abuse or suspected abuse could not be ruled out for 5 of 5 sampled residents (#s 4, 10, 20, 28 and 37). 1) During an interview on 12/04/23, Staff 9 (Activities, former RCC) stated the process for investigating and reporting incidents was as follows: *Call for help; *Assess for injuries and take vitals; *Call the resident's family, alert the resident's physician; *Notate incident in progress notes; *Fill out an incident report and pass it off to the executive director (ED) to send to the state. An incident report for Resident 4, dated 11/20/23, indicated Staff 9 (Activities) had witnessed another resident touching Resident 4 in a sexual manner. The local SPD office was not notified until 12/01/23. The facility self-report form was dated 11/13/23. 2) An incident report for Resident 10, dated 07/22/23, indicated s/he had experienced a witnessed fall resulting in pain in her right arm on 07/21/23. Witnesses were listed as "the community." There was no indication the facility investigated the incident immediately and adequately to rule out abuse, nor was there an indication an Administrator had reviewed the investigation. The incident report indicated it had been reviewed and completed by an RN on 10/17/23. The incident was not reported to the Department. 3) During an interview on 12/07/23, Staff 18 (Med Tech) stated Resident 20 had been given Resident 13's Morphine, Oxycodone, and Lorazepam by another med tech and failed to notify anyone. Resident 20's progress notes, dated 09/18/23, indicated s/he had accidentally been given another resident's medication and that his/her blood pressure was 98/55. Progress notes further indicated management had instructed staff to "get her up out of bed as soon as I could and was told to get her something caffeinated so I bought her a soda from the vending machine." There was no documented evidence of an investigation conducted by the facility. The incident was not reported to the Department. 4) Incident reports for Resident 28, dated 05/17/23, indicated s/he had suffered a fall with injury. There was no indication the facility investigated the incident immediately and adequately to rule out abuse, nor was there an indication an Administrator had reviewed the investigation. The incident was not reported to the Department. 5) Incident reports for Resident 37, dated 07/12/23, 07/13/23, 07/14/23, 08/15/23, and 09/27/23 indicated Resident 37 had suffered unwitnessed falls resulting in injury. There was no indication the facility investigated the incident immediately and adequately to rule out abuse, nor was there an indication an Administrator had reviewed the investigation. An incident report for Resident 37, dated 09/16/23, indicated s/he had suffered unwitnessed falls resulting in injury. There was no indication the facility investigated the incident immediately and adequately to rule out abuse. The incident report was completed by Staff 4 (Executive Director) on 09/19/23. The incidents was not reported to the Department. Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23. It was confirmed the facility failed to properly investigate and immediately notify the local Department office of multiple instances in which abuse or suspected abuse could not be ruled out. Verbal plan of correction: In service training for staff beginning immediately. A new administrator has been hired. Setting up formal systems including a drop box for incident reports and daily stand up with leadership team to review incidents.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to establish and maintain infection prevention and control protocols. Findings include, but are not limited to: 1. On 12/04/23 Resident 11 tested positive for COVID. During an interview on 12/04/23 Staff 3 (LPN) stated the facility was trying to test all residents but was out of COVID tests. During an interview on 11/04/23, Staff 6 (CG) stated s/he had changed Resident 11 but did not know s/he had COVID On 12/05/23 LCU was notified a second resident had tested positive for COVID. Staff were unable to confirm which resident had tested positive. Staff were observed on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23 not wearing masks. 2. During an interview on 12/07/23 Staff 4 (Executive Director) stated the facility did not have an infection control specialist. During an interview on 12/11/23 Staff 1 (Regional Director of Operations) stated the facility did not have an infection control specialist. Staff were observed on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23 not wearing masks. 3. During an interview on 12/04/23, Staff 7 (CG) stated the facility "frequently" runs out of briefs, gloves, masks, and trash bags, and that "someone will go to Fred Meyer if we need briefs". During an interview on 12/04/23, Staff 9 (Activities) stated "we do run out of supplies" such as gloves, briefs, and wipes. During an interview on 12/05/23, Staff 8 (MT) stated "it seems like we're always running out of wipes, gloves, [and] toilet paper." During an interview on 12/05/23, Staff 14 (MT) stated the facility had run out of gloves and a CG "had to go buy [gloves] with [his/her] own money." On 12/05/23 Staff 16 (CG) stated the following: - All hand soaps in every hall were out; - "We all run out of gloves and wipes;" - There were "no custodial people at all" and s/he had been "wiping dried poop off of the walls;" - The laundry was out of detergent, so they had been using a resident's detergent; - That morning the hall s/he was working in had run out of large and extra large briefs, and had one package of wipes left. On 12/05/23 LCU confirmed the facility was using a resident's detergent as the laundry detergent was out, that there was only package of wipes in the hall, and the hall was out of large and extra large briefs. On 12/05/23 Staff 3 (LPN) stated the facility had been short on supplies, "mainly gloves". On 12/07/23 Staff 15 (MT) stated the facility sometimes had "no supplies" such as gloves, wipes, and briefs. During an interview on 12/08/23, Witness 8 stated the facility had been out of briefs and s/he had bought some and brought them in his/herself. Confirmed. Verbal POC: Administration to review infection control protocols with staff 12/11/23 through 12/13/23. Infection control specialist will be new ED once they are trained. Facility has hired additional housekeeping staff through agency and walked every room for housekeeping. Facility is currently stocked with supplies and signs are in place.

Based on observation and interview, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23, and 12/11/23 it was determined the facility failed to fully implement an Acuity Based Staffing Tool (ABST) for 4 of 4 sampled residents (#s 2, 3, 15, and 18). Findings include, but are not limited to: During an interview on 12/11/23, Staff 1 stated the ABST should be updated upon move-in, anytime a resident experiences a change in condition, and anytime a resident's service plan was updated. A review of the facility's ABST indicated the following: *The facility used the ODHS ABST; *The facility's posted staffing plan did not match the ABST generated staffing plan as there were two care staff assigned to the 200 hall on 12/11/23 when the ABST indicated there should be three; *The ABST was not reflective of resident's needs for Residents 3, 15, and 18 as indicated by their service plans; and *The facility's ABST had not been updated for Resident 2 who was experiencing a change of condition. Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23. It was determined the facility failed to fully implement an Acuity Based Staffing Tool.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to: a. On 08/22/23 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: * The black and gray three tier shelf carts had food debris and crumbs; * The refrigerator below beverage station had splashes/splatter on the exterior and the interior bottom shelf had debris; * The hood vents above stove/grill had accumulation of grease and dust; * The reach in refrigerators and freezers had debris and crumb on the bottom shelves; * The spice shelves above prep area had dust and debris; * Behind the stove and grill had accumulation of dust and grease, the oven doors had food drips and splatters; * The ceiling and vents above the freezers and the clean dish washing area had dust accumulation, and the wall above clean dish washing area had dust accumulation; and * The interior of microwave had dried on food splatter. b. Two garbage cans were uncovered when not in use. The areas of concern were discussed with Staff 1 (Director of Dining Services) and Staff 2 (Executive Director) on 08/22/23. The findings were acknowledged.

Refridgerator under beverage station: Cleaned on 8/23/23. Added to daily cleaning task list and checking overflow. Maintenance Director also is checking overflow weekly for any water or other liquids and will service immediately if any needs are discovered or reported. Three shelf carts: Cleaned 8/22/23. Carts are on cleaning task list to be sanitized after each use, to include but not limit to beverage container deliveries and any other other usage. Hood vents: Cleaned on 8/23/23. Taking down, degreased, scrubbed, put through dishwasher and will be done monthly and added to monthly task list. Produce refridgerator: Cleaned 8/22/23. Spot clean daily, throughout the day. Deep clean once weekly. Shelves above prep area: Cleaned 8/22/23. Cleaning shelves daily at closing duties. Stove Cleaning: Inside and outside of stove has been cleaned 8/23/23. Behind stove scheduled to be cleaned 9/6/23. Inside, outside and around stove cleaning weekly. Ceiling vent above freezer and dish area: Maintenance Director and cooks will clean 9/1/23. Added to monthly task list and will be spot checked throughout the month. Interior of microwave: Cleaned 8/22/23. Will be cleaned twice daily. Garbage cans: Lids ordered 8/31/23. Once lids are delivered they will be on the garbage cans and have a hole cut in the top for quick use. Director of Dining Services will oversee these tasks get completed on the daily/ weekly/ monthly basis with Executive Director oversight

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

Refer to C240

The findings of the kitchen inspection, conducted 08/22/23, 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 first revisit to the kitchen inspection of 08/22/23, conducted 03/04/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the on-site investigation, conducted 08/03/2023 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 12/02/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 12/02/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 12/02/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 9/29/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 9/29/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the relicensure survey, conducted 04/11/22 through 04/14/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope and number of citations. Refer to deficiencies in report.

1. Once a week the ED will have a meeting with RCC(s) and RN to review their department. Clinical meetings conducted at least 2 times a week with RN and RCC(s) Once a week ED will meet with Regional Director of Operations to review administrative oversight plan. 2. Meeting logs will be kept to ensure these meetings are being conducted according to plan and resident care and services are being addressed. 3. This will initially be done on a weekly basis by RDO and ED 4. ED and RDO will monitor this is being completed

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors, and available for inspection at all times. Findings include, but are not limited to: The main entrance and lobby of the MCC was observed on 04/11/22 at 9:00 am. Observations showed: *  The Executive Director's name was posted as person in charge although the Executive Director was not in the building at the time. There was no system to display the designee in charge, posted by shift, or indicate when the administrator was out of the facility. *  The most recent re-licensure survey, including two revisits and plans of correction was not posted, and no copy of the survey was available when requested by the survey team. The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (Administrator) and Staff 2 (ED) on 04/11/22. They acknowledged the findings.

1. A dry erase board was posted on 4/13/22 above the keypad to the lobby doors indicating who the manager on duty is at all times during each shift. Most recent survey, revisit and letter of compliance was put into a binder and placed in the lobby in the glass cabinet under the TV on 4/14/22. 2. Med Tech who holds the staffing/after hours cell phone will write their name on the dry erase board once previous Med tech holding phone completes their shift exchange. This is apart of there shift change. ED will ensure that the most recent Survey and any revisits are in the binder and located in glass cabinet in lobby. 3. Required Postings will be monitored by receptionist daily. Additionally, QA audits will be used to evaluate 4. The Business Office Manager will be responsible to see that the corrections are completed/monitored

Based on interview and record review, it was determined the facility failed to maintain complete and accurate records for 2 of 7 sampled residents (#s 3 and 4) whose records were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 2017 with diagnoses including dementia. a. Between 02/09/22 through 04/11/22 staff documented in the progress notes the resident experienced three unwitnessed falls, two injuries of unknown origin, and was involved in a resident to resident altercation. Incident reports were requested on 04/12/22 at 8:30 am. Facility staff were not able to provide the reports until 04/13/22 at 2:00 pm. The reports contained incomplete documentation and the facility was unable to provide documentation that the reports had been reviewed and signed by the Administrator. 2. Resident 4 was admitted to the facility October 2021 with diagnosis including dementia and Parkinson's disease. a. Between 03/14/22 through 04/04/22 staff documented in the progress notes the resident experienced at least six falls. Incident reports were requested on 04/12/22 and 8:30 am. Facility staff were not able to provide the reports until 04/13/22 at 2:00 pm. The reports contained incomplete documentation and the facility was unable to provide documentation that the reports had been reviewed and signed by the Administrator. b. Resident 4 was receiving Hospice services from 03/08/22 through 04/11/22. Outside provider notes were requested for review on 04/12/22 at 8:30 am.  The documentation was not provided until 2:00 pm on 04/13/22. Staff were not able to locate the documentation initially stating "we changed our process" of handling the documents. The need to ensure the preparation, completeness, accuracy, and preservation of resident and staff records was reviewed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN) on 04/13/22. They acknowledged the findings.

1. For both resident 3 & 4 Administrator has signed all incident reports from dates 2/09/22 through 4/11/22 as of 4/25/22. Incident reports that were lacking documentation were updated and/or reported to state during time of survery visit. Resident records are currently being reorganized for a more speedy recovery of requested documents at any given time. 2. ED and RN will be reviewing all incident reports for completeness when reviewing and signing off. Since visit, resident binders, containing records, have been reorganized. Each binder will maintain a table of contents for med techs to properly file paperwork for ease in locating documents. 3. Binders will be purged and reviewed during each 90-day med review. Incident reports will be reviewed and signed off by Adminstrator or designatee in charge weekly 4. RN will be responsible for resident records ED will be responsible for incident reports and there completeness of

Based on interview and record review, it was determined the facility failed to promptly investigate unwitnessed incidents and injuries of unknown cause to rule out abuse, and failed to document all required areas of an investigation for 2 of 2 sampled residents (#s 3 and 4) with falls or injuries of unknown cause. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 2017 with diagnoses including dementia. A review of Resident 3's incident reports, post incident evaluations and progress notes dated 02/09/22 through 04/10/22 revealed s/he had three unwitnessed falls, was involved in a resident to resident altercation, and suffered two injuries of unknown cause. The incident reports did not document the information needed to immediately rule out abuse and neglect, including whether the service plan was being followed. The reports also lacked verification the incidents had been reviewed by the Administrator. During an interview with Staff 2 (ED) on 04/13/22, the process for reporting and investigating incidents was discussed. Staff 2 acknowledged the incident reports did not include documentation needed to sufficiently rule out abuse or neglect as well as the date and review of the Administrator. The need to ensure investigations contained the required documentation was discussed with Staff 1 (Administrator) and Staff 2 on 04/13/22. The incidents were self-reported to APS at request of the survey team, and confirmation was received during the survey. 2. Resident 4 was admitted to the memory care unit in 2021 with diagnoses including dementia and Parkinson's disease and had multiple unwitnessed falls. During an interview with Staff 11 (MT) s/he stated Resident 4 was dependent on staff for most ADL care would often stand and walk independently and required stand by assistance of at least one person for transfers related to safety. A review of Resident 4's incident reports, post incident evaluations and progress notes dated 01/10/22 through 04/10/22 revealed s/he had six unwitnessed falls. The incident reports did not document the information needed to immediately rule out abuse and neglect, including whether the service plan was being followed. The reports also lacked verification the incidents had been reviewed by the Administrator. During an interview with Staff 2 (ED) on 04/13/22, the process for reporting and investigating incidents was discussed. Staff 2 acknowledged the incident reports did not include documentation needed to sufficiently rule out abuse or neglect as well as the date and review of the Administrator. The need to ensure investigations contained the required documentation was discussed with Staff 1 (Administrator) and Staff 2 on 04/13/22. They acknowledged the findings and Staff 2 stated the electronic system would be modified to show the review and signature of the Administrator.

1. All incident reports for Resident 3 & 4 have been reviewed for completeness. Incidents that had not been clearly ruled out for abuse and neglect have been reported during time of survey (as stated on pg.13). All incident reports from that period have been signed off on from ED. (Resident 4 passed away on 4/21/22) All staff will be in-serviced on abuse reporting. 2. ED and RN will be reviewing each incident report before signing off and locking them to ensure complete and appropriate documentation has happened. Our policy and prodecure for abuse and neglect reporting has been reviewed with RCCs. 3. ED will initalling be reviewing incident reports with RCC's weekly to ensure proper documentation and reporting has occurred. 4. RN and ED will be responsible to see that the corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The main facility kitchen and the four neighborhood kitchenettes were toured on 04/11/22 at 10:47 am. The following areas were in need of cleaning or repair: * There was dirt and dust build-up on and surrounding the ceiling ventilation units; * Multiple appliances throughout the kitchen had visible layers of dust, dirt, and / or food debris, including on the ice machine, the juice dispenser, the stand mixer, and the ovens; * The three refrigerators had visible food debris and drips on the doors and the floors of the units; * The handwashing sink near the beverage counter had a leak from the faucet; * The small refrigerator under the beverage counter had black residue along the seal; * The industrial can opener had black/brown grease in the holding sleeve; * The standing freezer had dried food debris on the floor of the unit; * The floor drains throughout the kitchen were covered in brown stains and food debris; * Surfaces throughout the kitchen were covered with dust, stains, food debris, and dirt, including the shelves of the steam table, under the steam table, on the door by the prep counter, on shelving under the cutting boards, on the wall behind both handwashing sinks, on floors throughout the kitchen, and on the floor in the dry storage area; * The metal back splash behind the three compartment sink had dried food debris and a white residue and the caulking was pink/black; * The drawers in all four kitchenettes had food debris, dirt, staining and / or dust on the edges and within the drawers; * The microwaves in all four kitchenettes had food debris inside the appliance and outside on the control panel; * The cabinets and counter surfaces in all four kitchenettes had laminate lifting or worn sealant exposing particle board; * The steam tables in two kitchenettes had food debris, spills, and brown markings; and * Soiled cloth napkins and clothing protectors were left in the cabinets of two of four kitchenettes. The areas needing cleaning and repair were reviewed with Staff 6 (Dining Services Director) and Staff 2 (ED) on 04/11/22. They acknowledged the findings.

1. a) MD (maintanence director) will clean all vents in the community. b) Dining Service Team will thoroughly clean all kitchen appliances including and not limited to: ice machine, juice dispenser, stand mixer and ovens. c) Dining Service Team will thorughly clean all refridgerators inside and out of all food debris. d) Leak from the faucet in the handwashing station in kitchen has been repaired. e) Fridge under beverage counter will be thoroughly wiped clean inside and out. f) Can opener will be thoroughly wiped cleaned g) Standing freezers on units will be thouroughly wiped clean h) All surfaces in the kitchen including: shelves of the steam table, door by prep counter, shelving under cutting boards, walls behind handwashing sinks and all floors in kitchen will be thoroughly cleaned and wiped down. i) Metal back splash and wall behind the three compartment sink will be thoroughly wiped clean. Caulking will be replaced. j) Drawers in Kitchenettes will all be thorughly wiped clean inside and out. k) Microwaves in all four Kitchenettes will be thoroughly wiped clean inside and out. l) Counter and cabinet laminate will be replaced by the MD. For areas that are not easily replaced, apoxy will be applied in order to create a cleanable surface. m) Steam Tables in Kitchenettes will be thoroughly wiped clean. n) Soiled cloth napkins will be placed in an appropriately labeled bin in in cabinet of the kitchen. 2. *Maintanence Director will have a Quarterly vent and faucet inspection. This documentation will be kept in an inspection binder by the Maintanence Director. *A cleaning and inspection log will be kept by the Dining Services Team that will encompass each individual example listed above and not limited to: Counter surfaces, floors, sinks, ice machines, juice machine, appliances, can opener, refidgerators, freezers, walls and shelves. For all cleaning needs that are to be met by Care staff, Dining staff will conduct an inspection of their kitchenettes and identify areas that pass or do not pass cleanliness inspection that include and are not limited to: Microwave, counters, drawers, cabinets, refridgerator, freezer, soiled linens and steam tables. 3. Inspections of Kitchenettes will occur weekly and cleaning logs for Kitchen will be done daily/semi-monthly/monthly. See below for more detail: Daily: Counters, Sinks, Juice machine, Appliances, floors Semi-monthly: Walls, Refridgerators, freezers, shelves Monthly: Vents 4. *Dining services will ensure that the following corrections happen and montior their continuation, b, c, e, f, g, h, i, j, k, l, m & n   * Maintanence Director will ensure a and d are corrected and monitored

Based on observation and interview, it was determined the facility failed to ensure the kitchenettes and bistro were clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: The four neighborhood kitchenettes and bistro were toured on 08/09/22 at 9:20 am. The following areas were in need of cleaning or repair: 1. Community kitchenettes * The cabinets and counter surfaces in all four kitchenettes had laminate missing, lifting or worn, exposing particle board; * The drawers in all four kitchenettes had debris on the edges and fronts of the drawers; * The refrigerator kickplate had food debris and dirt in all four kitchenettes; * In the Broadway kitchenette, the right island cabinet front was missing; and * In the Fremont kitchenette, the island right side panel had a gouge, exposing wood underneath. 2. Community bistro * The countertop next to the sink was lined with dominoes that had green, orange, and red liquid debris on them; * The refrigerator had food debris and drips on the inside bottom and doors of the unit; * The refrigerator had debris along the seals of the doors; and * The left cabinet bottom shelf had exposed particle board and yellow staining. The areas needing cleaning and repair were reviewed with Staff 2 (ED) and Staff 30 (ED) on 08/10/22. They acknowledged the findings.

1) Community Kitchenette cupboards, drawers and fridge kickplates have been wiped clean. We have received 3 bids for countertop refinishing/replacement and will be making a decision on repairs this week. Maintenance Director has material to begin replacing missing laminate on cupboard doors and drawers in kitchenette's and community bistro. Domino's from counter in Bistro have been removed and leaking soap dispenser has been removed and will be replaced with a new dispenser by Maintenance director. Fridge in community bistro has been wiped clean and organized. 2) Maintenance Director will maintain an adequate supply of extra laminate to repair any damages on cupboards/drawers moving forward. Community Bistro cleanliness will be maintained daily by Activities Assistants and/or Director. 3) Damaged to cupboards/countertops will be reported on TELS for Maintanence director to address, Maintanence director will monitor countertops and cabinet faces for damages monthly and make repairs as needed. Activities staff will check off adequate cleanliness of their kitchenette area once weekly. 4) Maintanence Director and Activities Director

Based on observation and interview, it was determined the facility failed to ensure the kitchenettes and bistro were clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: The four neighborhood kitchenettes and bistro were toured on 12/12/22 from 10:15 am to 10:50 am. The following areas were in need of cleaning or repair: 1. Community kitchenettes * Cabinets and counter surfaces in all four kitchenettes had laminate missing, lifting or worn, exposing particle board; * Drawers in all four kitchenettes had debris on the edges and fronts of the drawers; * In the Broadway kitchenette, the right island cabinet front was missing; and * In the Fremont kitchenette, the island right side panel had a gouge, exposing wood underneath. 2. Community bistro * The left cabinet bottom shelf had exposed particle board and yellow staining. The areas needing cleaning and repair were reviewed with Staff 1 (ED)  on 12/13/22. She acknowledged the findings.

1. Countertop replacement and cabinets refinish is scheduled to be completed by Restoration and Cabinetry by January 31st, 2023 for each neighborhood Kitchenette (Extension Granted by Jeanne Bristol via email) 2. The Maintenance Director will examine kitchenette counter tops and cabinetry and make necessary repairs as they occur. Any damages that are beyond our ability to repair we will address with Restoration and Cabinetry 3. Monthly and as needed 4. Maintenance Director and ED

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and were followed, and failed to provide clear direction to staff for 3 of 5 sampled residents (#s 4, 5 and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 2018 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the service plan updated 04/12/22 and 01/27/22 thru 04/11/22 progress notes, showed the plan was not reflective and did not provide clear direction to staff in the following areas: * Emergency evacuation status; * Assisting dressing/undressing status; * Bathing status; * Communication status; * Grooming; * Oral hygiene and shaving status; * Managing of glasses status; * Assisting with toileting including use of urinal; * Mobility status, use of wheelchair versus bed bound; * Bed mobility status; * Outside provider services; and * Use of scoop mattress.   The need to ensure the resident service plans were reflective and provided clear directions to staff was discussed with Staff  2 (ED) on 04/13/22. Staff acknowledged the findings. 2. Resident 7 was admitted to the facility in 2021 with diagnoses including Alzheimer's disease. Observations of the resident, interviews with staff and review of the service plan updated 09/27/21, showed the plan was not followed in the following areas: * Walk to the kitchen with the resident for every single meal; * Offer a chocolate protein shake when trouble eating; and * Warming up food prior to giving it to the resident. The need to ensure the resident service plans were followed was discussed with Staff  2 (ED) and Staff 3 (RN) on 04/13/22. Staff acknowledged the findings. 3. Resident 4 was admitted to the facility in 2021 with diagnoses including dementia and Parkinson's disease. Observations of the resident from 04/11/22 through 04/13/22, a review of temporary service plans and the current service plan completed on 03/26/22, showed the plan was not reflective of the resident's needs and did not provide clear direction to staff in the following areas: * Use of a geri-chair when out of bed and a tray during meals; * Current precautions in place to prevent falls and injury from falls; * Hospice services providing bathing assistance; * Current activity needs and preferences; * When and how to provide meal assistance, eating patterns and hydration; and * Instructions for staff related to when to pull down their face masks to allow the resident to read their lips during communication. In an interview on 04/12/22, Staff 4 (RCC) stated the resident's service plan was being reviewed by the resident's family member and had not yet been returned. Staff 4 stated the resident had been using the geri-chair as provided by Hospice. On 04/13/14, Staff 4 provided copies of temporary service plans (TSP's) that had been completed from 02/04/22 through 03/09/22. The TSP interventions had not been included in the evaluation or service plan completed on 03/26/22. The need to ensure the resident service plans were reflective of resident needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff  2 (ED) on 04/13/22. They acknowledged the findings.

1. Service plan for resident #7 was updated and care conference was conducted with POA and Ombudsman (who joined via zoom) on 4/15/22. Resident 4 passed away (4/22/22)   Resident 5 passed away (4/14/22) 2. Direct care staff must read, sign and date resident service plans timely to indicate their understanding of what is in each residents service plan. When a TSP or Newly updated service plan is placed in the binder it will be flagged to inform direct care staff to review changes. RCCs will be in-serviced on Service planning, evaluations, TSPs and will in turn educate direct care staff of the importance of a service plan and how to provide person centered care using a service plan. 3. Signatures will be reviewed by Health Services team, once there are 5-10 signatures, TSP/Service plan will be unflagged. 4. RCC's will be responsible for the completion of these corrections as well as monitor that they continue to happen

2.  Resident 10 was admitted to the facility in 03/2022 with diagnoses including dementia. a.  During interviews with Staff 5 (RCC), Staff 11 (MT), Staff 28 (CG) and Staff 29 (MT) on 08/09/22, they described the following behaviors: * Resident 10 threatened staff and residents with his/her cane; * The resident was agitated and had behaviors daily, including wanting to go home; * The resident was exit seeking and had a history of eloping; * Staff made sure exit doors were closed quickly when visitors left the facility to reduce the opportunity for Resident 10 to leave with a visitor; * Resident 10 accused staff of trying to "lock [me] up"; * Resident 10 frequently refused to take medications; * There was a particular resident that staff had to direct Resident 10 away from; * Staff offered the resident tea during times of agitation; * Staff made plans with Resident 10 to get in touch with family; * Keeping the door open to the bistro area helped minimize behaviors; and * Walking away from the resident and re-approaching later was helpful to diffuse behaviors. Resident 10 was observed during the survey to be in the Broadway neighborhood or bistro area. When interviewed on 08/09/22 at 11:13 am, Resident 10 stated s/he wanted to "get out of this place." Resident 10's current service plan, dated 05/22/22, was not reflective of the resident's behaviors, including specific behaviors demonstrated, exit seeking and elopement history, nor were there specific instructions to staff regarding approaches to attempt when the resident was agitated. b.  Resident 10's current service plan noted the resident required assistance with shaving his/her upper lip and chin. Staff were directed to assist the resident to the bathroom, have the resident stand at the sink, use shaving cream and a disposable razor to shave and provide a warm wash cloth to clean his/her face. Resident 10 was observed on 08/09/22 and 08/10/22 to have long hair on his/her upper lip and chin. During an interview with Staff 29 (MT) on 08/09/22 at 11:20 am, she verified the resident had facial hair on the upper lip and chin and had not been shaved. Resident 10's service plan was not followed related to providing assistance with shaving. Resident 10's service plan was discussed with Staff 2 (ED) and Staff 3 (RN) during the survey on 08/10/22. Staff 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, were readily available to staff, provided clear direction regarding the delivery of services and were followed for 2 of 4 sampled residents (#s 9 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in 02/2020 with diagnoses including dementia and anxiety disorder. Review of the service plan revealed the following: a. The service plan, readily available to caregiving staff in the service plan binder on the unit, was dated 03/12/22. During an interview on 08/09/22 at 3:02 pm, the surveyor asked Staff 3 (RN) if the caregiving staff had any additional way to access the most recent service plan, dated 07/11/22. She confirmed the CGs only accessed the service plan through the binder located in the unit, and the most recent updated service plan was located in the locked medication room in the resident's chart. b. Observations and interviews with staff revealed the service plan available to staff failed to provide clear direction to staff and was not reflective in the following areas: * Bathing schedule for hospice staff and facility staff; * ADL assistance and cueing; and * Behavior management techniques related to the relationship with another resident. The need to ensure a current service plan was available to staff, provided clear direction and was reflective of the residents' current needs was discussed with Staff 3 on 08/10/22 at 11:08 am, Staff 2 (Executive Director) and Staff 30 (Executive Director) on 08/10/22 at 12:42 pm, and Staff 2, Staff 3 and Staff 30 at survey's exit. They acknowledged the findings. No further information was provided.

1) Resident 9 and 10's service plans have been reviewed and updated appropriately to emcompass their behaviors, interventions and ADL needs. Care conferences have been scheduled with families to ensure satisfaction of changes/updates and updated Service plans have been placed on their perspective units for care staff to follow. 2) RCC's will ensure that TSP's are being placed on the floor when necessary, quarterly service plan reviews are taking place and when a service plan is updated it is printed and placed on the floor for staff to follow. 3) These updates will happen at least quarterly and as needed when changes happen with residents 4) RCC's and RN

2. Resident 14 was admitted to the facility in 10/2019 with diagnoses including dementia. Observations of the resident and interviews with staff during the survey, and review of the clinical record including the 10/25/22 service plan and Temporary Plan of Care (TSPs) from 09/21/22 through 12/04/22, revealed the service plan was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas: * Mobility status; * Use of side rails; * Emergency evacuation status; and * Transfer status. The need to ensure the service plan was reflective of Resident 14's current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 18 (Resident Care Coordinator) on 12/13/22. 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, were readily available to staff, and provided clear direction regarding the delivery of services for 2 of 4 sampled residents (#s 12 and 14) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 12 was admitted to the facility in 03/2017. A review of the resident's clinical record showed the most current service plan was updated 11/17/22. The service plan was not available to direct care staff for review. The resident's 11/17/22 service plan was reviewed and stated the following: "... is at increased risk of choking and aspiration due to recent development of difficulty swallowing and several coughing/choking incidences. Please supervise at meals and offer [him/her] soft foods if [s/he] is unable to safely swallow the meal provided" In an interview on 12/13/22 at 11:50 am, with Staff 18 (RCC) and Staff 36 (RN), they confirmed this updated information had not been made available to staff. The need to ensure service plans were available to care staff, reflective of residents current needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 18 and Staff 36 on 12/13/22. They acknowledged the findings.

1. Service plans have been updated and distributed for all staff to review and sign. An audit of Service plan binders from each hall has been completed to ensure that most up to date service plans are available for staff. 2. A checklist has been implemented for RCC/RN to use when updating a residents service plan that includes ensuring the service plan is printed and readily available to staff. In addition, Service plan binders will be audited weekly to ensure staff have been reviewing any changes and most up to date service plans have been placed in binders. 3. Weekly 4. RN, ED & RCC

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: Current service plans for Residents 1, 3, 4 and 5 were reviewed during the survey. There was no documented evidence that a Service Planning Team reviewed and participated in the development of the service plans. On 04/13/22 the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN). They acknowledged the findings.

1. Resident 4 & 5 have passed since survey has ended. Resident 1 & 3 have had service plan updates done by RCC, reviewed by RN and conducted care conferences with POA. 2. All service plan updates moving forward will have a signature from the RCC who was involved in updating the plan, Signature from the RN or ED who reviewed the updated plan and Signature from POA who attended the Care Conference and reviewed Service Plan with service planning team. 3. This will be done quarterly 4. Health Service Director and ED will be responsible to see that this is being done

Based on observation, interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for a resident or failed to monitor short term changes of condition through resolution for 4 of 4 sampled residents (#s 1, 3, 4 and 5) reviewed with changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2021 with diagnoses including dementia. The current service plan dated 03/24/22 noted the resident required assistance and cueing with ADLs. The resident was identified to have aggressive behaviors and there were clear directions on how to approach and provide care for the staff. Review of progress notes and incident reports between 01/10/22 through 04/07/22 noted the following changes of condition: * 01/06/22 incident report noted the resident was observed standing over another resident and had a "small bruise to right cheek"; * 01/14/22 The resident "bit a staff member ...while attempting to provide care ..." * 03/06/22 " ...hit resident in the head with a cup." * 03/12/22 " ...resident punched MT in the face and broke glasses ..." * 03/14/22 " ...suddenly [resident] grabbed my arm pulled me down and punched me in the [right] eye." * 03/18/22 "...red rash in the groin area...apply barrier cream with each incontinence change." Interviews with staff identified the resident was combative and at times aggressive during care. Resident 1 was observed during the survey to be primarily in bed sleeping or eating a meal in the dining room. *There was no documented evidence the resident altercations were evaluated to determine new actions or interventions to attempt to minimize future occurrences and no documented evidence service planned interventions were reviewed to determine if they continued to be effective. *There was no documented evidence the changes of condition dated 01/06, 01/14, 03/06 and 03/18 were monitored through resolution. Reviewing changes of condition to determine if actions or interventions were developed or if service planned interventions were reviewed for effectiveness was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN) on 04/13/22 at 1:00 pm.  No additional information was provided. 2. Resident 3 was admitted to the facility in 2017 with diagnoses including dementia and anxiety. A review of the clinical record revealed the following: * On 02/09/22 Resident 3 experienced a fall, then fell again on 03/02/22. There was no documented evidence that service-planned interventions to prevent falls were reviewed for effectiveness or if new interventions were needed following each fall; and   * On 03/11/22 a progress note documented the discovery of an injury of unknown origin "Resident had a quarter sized yellow bruise above Left eyebrow". An incident report regarding the injury noted "possibly from found on floor incident 3/2". There was no documented evidence the injury was monitored until resolution. The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution and that fall interventions were reviewed to determine if they were effective was shared with Staff 1 (Administrator) and Staff 2 (ED) on 04/13/22. They acknowledged the findings . 3. Resident 5 was admitted to the facility in 2018 with diagnoses including dementia. Observation and interview with staff during the survey indicated the resident required staff assistance with transfers and bowel and bladder management. Progress notes dated 01/10/22 through 03/22/22 indicated the following: * 01/27/22 - The resident was on alert charting due to episode of vomiting and high blood pressure. There was no documented evidence the change of condition was monitored through resolution. On 04/13/22, Resident 5's progress notes were reviewed with Staff 2 (ED). Staff acknowledged the findings. 4. Resident 4 was admitted to the facility in late 2021 with diagnoses including dementia and Parkinson's disease. A review of the clinical record revealed the following: a. Resident 4 experienced six falls between February and April, 2022. The facility failed to determine if service-planned interventions were effective or if new interventions were needed following each fall. Additionally, there was no documented evidence the facility monitored and documented on the progress of skin injuries sustained, following the falls on 03/29/22 and 04/03/22, at least weekly until resolved. b. On 03/09/22, the resident received physician orders to start two new medications. There was no documentation of monitoring any potential adverse effects or the effectiveness of the medications following starting them. The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution and that fall interventions were reviewed to determine if they were effective was shared with Staff 1 (Administrator) and Staff 2 (ED) on 04/13/22. They acknowledged the findings.

1. In-service staff on alert charting, appropriate monitoring and reporting. Retraining on the 24-hour communication binders for both Med Tech and Care Partner. Policy and procedures have been reviewed with all direct care staff and management for this tag. 2. RCC and/or RN will review communication binders daily (See signature page for proof of review from RN/RCC). Change of Condition will be completed by RN within 24-hours and will review with Service planning team to include but not limited to: POA, Staff, resident, RCCs, Dining Service and any Outside Providers if necessary. Service plan will reflect current changes, needs that are specifc to that resident, or TSP will be implemented with personalized interventions. Additionally, QA aduits will be used to evaluate 3. This will be evaluated by RN within 30-days of significant Change. 4. RN will be responsible to see that the correntions are completed/monitored.

2. Resident 6 was admitted to the facility in 10/2021 and had diagnoses which included dementia and insulin-dependent diabetes. Resident 6's clinical record and progress notes 06/01/22 through 08/09/22 were reviewed and revealed the following: a. On 06/13/22, s/he was placed on alert because s/he "threw [him/herself] off of [his/her] bed onto the floor ..." The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term change in condition. b. Resident 6 had a decrease in his/her insulin on 06/17/22. Monitoring was initiated, yet there was no documented evidence the facility monitored and documented on the short-term change in condition until resolved. Additional information was requested on 08/10/22. On 08/10/22 at 1:25 pm, Staff 3 (RN) reported she reviewed the resident's record and concluded the short-term changes in condition had not been monitored until resolved. No further information was provided. The need to ensure short-term changes in condition were monitored until resolution was discussed with Staff 2 (ED) on 08/10/22 at 1:35 pm. She acknowledged the findings. 4.  Resident 10 was admitted to the facility in 03/2022 with diagnoses including dementia. Resident 10's clinical record, progress notes from 06/08/22 through 08/07/2, and physician communication records were reviewed and noted the following: * On 07/02/22 a physician communication note revealed Resident 10 exhibited "...aggressive behaviors, hitting people with [his/her] cane ... really angry about not being able to go home and makes self harm threats." There was no documented evidence the facility identified what actions or interventions were needed for the resident, and there was no evidence the resident had been monitored following the communication to the doctor. Resident 10's short-term change of condition related to self harming threats and lack of evaluation to determine what actions or interventions were appropriate and monitoring until resolved was discussed with Staff 2 (Executive Director) and Staff 3 (RN) on 08/10/22. Staff acknowledged the finding. 3. Resident 9 was admitted to the MCC in 02/2020 with diagnoses including dementia and anxiety disorder. The clinical record and progress notes, dated 06/14/22 through 08/08/22, were reviewed and revealed the following: Resident 9 was placed on alert charting following a witnessed non-injury fall on 07/23/22. The facility initiated alert charting the same day. However, there was no documented evidence the facility monitored the resident weekly through resolution. During an interview with Staff 3 (RN) on 08/10/22 at 11:08 am, additional documents were requested to support weekly monitoring through resolution for this short-term change of condition. No additional documents were provided by survey's exit. The need to ensure the facility monitored short-term changes of condition with weekly progress noted until resolution was discussed with Staff 2 (Executive Director), Staff 3 and Staff 30 (Executive Director) on 08/10/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed when residents experienced changes of condition, communicate the actions and interventions to staff and monitored weekly progress until the conditions resolved for 4 of 4 sampled residents (#s 6, 8, 9 and 10) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 07/2020 with diagnoses including Alzheimer's disease and anxiety disorder. Resident 8's medical record was reviewed. The following deficiencies were identified: a. A Physician Communication on 06/16/22 noted " ...abdominal pain when urinating. [S/he] has also been more emotional and had two episodes of diarrhea since yesterday." There was no documentation of actions or interventions determined or monitoring at least weekly until resolved. b. Interventions for falls on 06/26/22 and 06/28/22 were not communicated to staff and monitored at least weekly until resolved. The need to determine and document what actions and interventions were needed for the resident when s/he experienced short-term changes of condition, communicate them to staff, and monitor them at least weekly through resolution was discussed with Staff 2 (ED), Staff 3 (RN) and Staff 30 (ED) on 08/10/22. They acknowledged the findings.

1) Resident's 8, 6, 9 and 10 charts and progress notes have been reviewed and updated for monitoring and resolution. 2) Clinical meetings will be conducted to review progress notes, alert charting and end of shift binders in order to ensure monitoring and/or resolution is happening with residents who are placed on alert or have any type of change in condition. 3) Daily 4) Executive Director and RN

2.  Resident 6 was admitted to the facility in 2021 with diagnoses including dementia, and type II diabetes. Resident 6's weight record was reviewed during the survey and revealed the following: * 02/2022 - 141.8 pounds; * 03/2022 - 152.6 pounds; and * 03/31/22 - 153.3 pounds. From 02/2022 to 03/2022, Resident 6 had gained 10.8 pounds or 7.6 % of his/her body weight, which represented a significant change of condition that required an RN assessment. There was no documented evidence the facility RN assessed the resident's condition related to the weight gain. On 04/13/22 at 1:30 pm with Staff 2 (ED) confirmed that there was no RN assessment related to the significant weight gain. On 04/13/22 and 04/14/22, the need to ensure the facility RN completed an assessment for a significant change of condition was discussed with Staff 2 and Staff 3 (RN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 3 sampled residents (#s 4 and 6) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in October 2021 with diagnoses including dementia and Parkinson's disease. Progress notes, dated 02/23/22, showed Resident 4 was sent out to the hospital for evaluation and treatment of a significant change in behaviors and cognition. The resident returned to the facility on 03/06/22 and was sent out to the hospital again on 03/06/22 for a decline in cognition. Upon the resident's return to the facility on 03/08/22, s/he was admitted to Hospice services. The decline in the resident's condition and admission to Hospice services represented a significant change of condition. In an interview on 04/12/22, Staff 2 (ED) and Staff 3 (RN) stated an RN assessment had not been conducted and there was no documentation available. The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment for significant changes of condition was discussed with Staff 1 (Administrator), Staff 2, Staff 3, and Staff 26 (Nursing Consultant) on 04/13/22. They acknowledged the findings.

1. In-service staff on alert charting, appropriate monitoring and reporting. Retraining on the 24-hour communication binders for both Med Tech and Care Partner. Policy and procedures have been reviewed with all direct care staff and management for this tag. 2. RCC and/or RN will review communication binders daily (See signature page for proof of review from RN/RCC). Change of Condition will be completed by RN within 24-hours and will review with Service planning team to include but not limited to: POA, Staff, resident, RCCs, Dining Service and any Outside Providers if necessary. Service plan will reflect current changes, needs that are specifc to that resident, or TSP will be implemented with personalized interventions. Additionally, QA aduits will be used to evaluate 3. This will be evaluated by RN within 30-days of significant Change. 4. RN will be responsible to see that the correntions are completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN for 1 of 1 sampled resident (#9) reviewed for significant changes of condition. This is a repeat citation. Findings include, but are not limited to: Resident 9 was admitted to the facility in 02/2020 with diagnoses including dementia and anxiety disorder. During the entrance conference on 08/09/22, staff reported the resident had a recent decline in ADL status and was currently on hospice services. Review of the clinical record revealed the resident was admitted to hospice on 06/15/22 with a diagnosis of Alzheimer's disease. During an interview with Staff 3 (RN) on 08/10/22 at 11:08 am, she confirmed the resident's decline was sudden, and she observed the resident sleeping more frequently during the day, eating fewer meals, having increased difficulty with expressive communication, and exhibiting frequent changes in mood. The decline in health and admission to hospice constituted a significant change in condition, for which an assessment by an RN was required. The surveyor requested the RN assessment on 08/10/22 at 11:08 am. The facility provided no documented evidence an RN assessment was conducted. The need to ensure an RN assessment was completed following a significant change of condition was discussed with Staff 2 (Executive Director), Staff 3 and Staff 30 (Executive Director) on 08/10/22. They acknowledged the findings, and no additional documentation was provided.

1) Resident 9's chart and progress notes have been reviewed and updated for change in condition, admit to hospice. RN assessment has been completed 2) Clinical meetings will be conducted to review progress notes, alert charting and end of shift binders in order to ensure monitoring and/or resolution is happening with residents who are placed on alert or have any type of change in condition. RCCs, RN and ED with be in-serviced by nurse consultant team Allen Flores on significant change in conditions. 3) Daily 4) Executive Director and RN

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for residents who had significant changes of condition which included documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#14) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to: Resident 14 was admitted to the facility in 09/2019 with diagnoses including dementia. During the entrance conference on 12/12/22, staff reported the resident had a recent decline in ADL status and was currently on hospice services. The resident was observed on 12/12/22 in the dining room for lunch and required hands on assistance with meal intake. Resident 14's progress notes from 09/22/22 to 12/12/22 and incident reports were reviewed during the survey and revealed the following: * The resident had six falls including four emergency department visits; * 09/24/22 progress note - The "resident is having a hard time wallowing [swallowing] the ABX [antibiotic]; * 10/15/22 note - "Resident appeared a little extra tired...was having a hard time eating..."; * 11/04/22 note - "Needing assistance sitting up"; * 12/05/22 note - Resident "is slowly declining. Cannot really walk and now has to be fed every meal..."; and * 12/08/22 - The resident was admitted to the hospice service. The decline in health and admission to hospice constituted a significant change in condition, for which an assessment by an RN was required. There was no RN assessment for the significant change of condition at the time of survey. In an interview on 12/12/22 at 2:00 pm, Staff 36 (RN) confirmed that she had not completed the assessment of the resident's condition. The need to ensure significant changes of condition were assessed by an RN and the assessment included documentation of findings, the resident's status, and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 36 (RN/Director of Health Services) on 12/12/22 and 12/13/22. They acknowledged the findings.

1. The week prior to this revisit, our Nurse completed the Community Based Care course. During this course she was taught the guidelines of significant changes in community based care. The Nurse completed this change of condition before surveyors left. Going forward the RN will be notified of Significant changes in a timely manner 2. The Nurse will complete any Significant change of condition assessment within 48 hours of change in resident. Staff will be in-serviced on significant change and how to report to RN 3. Audit a random 4 residents once weekly 4. ED or designee

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 6) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task. Resident 6's MARs, reviewed from 03/01/22 through 04/11/22, revealed insulin had been given by Staff 9 (CG/MT), Staff 10 (MT) and Staff 11 (MT) on multiple occasions. Delegation records for Resident 6, were reviewed on 04/11/22 and 04/12/22 and revealed the following: * There was no RN assessment including documented evidence to determine that the resident's condition was stable and predictable, prior to deciding to delegate the task; * Transfer delegation was completed on 04/01/22. There was no documented evidence the incoming RN reviewed Resident 6's condition that there was no RN assessment for the resident's diabetic condition completed by the outgoing RN; * There was no current facility RN assessment including how the RN determined the resident's condition was stable and predictable to continue delegation of the task, given the resident had experienced CBGs greater than 600 on multiple occasions; * There were no documented evidence Staff 9, 10 and 11 were delegated for the insulin administration to Resident 6 including the staff's skills, abilities and willingness for the delegation tasks; and * There was no rationale, based on the competency of the unlicensed staff, for how frequently the unlicensed staff should be supervised and re-evaluated. The need to ensure staff who administered insulin injections was delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (ED) and Staff 3 (RN) on 04/12/22 and 04/13/22. Staff acknowledged the findings.

1. RN will review all diabetic Orders for Insulin and CBG's and ensure parameters are specific to each resident and following community policy. MT training will be conducted on signing of medications, delegated staff per policy and regulation. 2. RN taking over delegations will include training, medication administration, delegation roles, signing of medications, parameters and who to call/when to call. 3.Nursing team (RN/RCC) to review insulin administration weekly to ensure this is being done properly. 4. RN will be responsible to see that the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to have a system to coordinate care with outside providers in order to ensure the continuity of care for 1 of 1 sampled resident (#4) who received services from an outside provider. Findings include, but are not limited to: Resident 4's clinical record was reviewed during the survey. On 04/12/22, the surveyor requested outside provider notes for review. Multiple staff interviewed were unaware of where to locate the documentation. On 04/13/22, Staff 4 (RCC) provided copies of Hospice provider notes from visits from 03/25/22 through 04/04/22. a. On 04/01/22, a Hospice provider documented "encourage staff to allow [patient] to rest in bed if drowsy, support with pillow on left side when awake in chair".  There was no evidence this recommendation had been reviewed and communicated for facility staff to follow. b. The outsider provider notes lacked documented evidence they had been reviewed by facility staff for any recommendations made by outside providers. In an interview on 04/03/22, Staff 4 and Staff 3 (RN) explained the facility was planning to start a new process for reviewing outside provider notes that would include having the notes reviewed by facility staff. The need to coordinate on-site health services with outside service providers, ensure that staff were informed of new interventions and that the service plan was adjusted if necessary was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 on 04/13/22. They acknowledged the findings.

1. RN/RCC will be in-serviced on policy and procedures of receiving and documenting outside provider notes. 2. RN reviews all outsider notes and nuring team will taken outsider orders and TSP's, Service plans, communicate with staff of new orders or changes and ensure MT and other appointed staff are documenting on these changes. 3. Daily 4. RN will be responsible to see that the corrections are completed/monitored

Based on interview and record review, it was determined the facility failed to ensure adequate professional oversight for safe medication administration systems and for 1 of 5 sampled residents (# 6) whose medication records were reviewed. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 2021 with diagnoses including Type II Diabetes. Resident 6 had a physician's order, dated 03/04/22, to check CBGs before meals and before bed. * Resident 6's 03/01/22 through 04/11/22 MAR and progress notes from 03/01/22 through 04/11/22 revealed staff either did not check CBGs or checked CBGs after meals on multiple occasions. * Resident 6 had CBG readings of 600 on 34 occassions between 03/01/22 and 04/11/22. Staff 2 (ED) and Staff 3 (RN) were interviewed on 04/12/22 and 04/13/22 and stated the facility glucometer could not register a CBG reading above 600. Direct care staff had not reported the readings to the facility RN. Refer to citations C 282, C 303 and C 310 for additional information. 2.  On 04/13/22 at 02:30 pm, the findings were reviewed with Staff 1 (Administrator), Staff 2, Staff 3 and Staff 26 (Nursing Consultant). Facility staff were unable to provide evidence of who was responsible for oversight of the medication administration system. 3. Administrative Oversight of the medication and treatment administration system was also found to be ineffective, based on deficiencies in the following areas: C 282: Delegation; C 303: System: Medication and Treatment Orders; C 310: System: Medication Administration; and C 315: System: Treatment Administration. The need to provide oversight and safe medication and treatment administration systems approved by a pharmacist consultant, registered nurse, or physician was reviewed with Staff 1, Staff 2, Staff 3 and Staff 26.  No additional information was provided.

1. RN will over see medication administration system, med tech trainings, administration and orders. All med techs will have completed a competency checklist, signed by RN. There will be doucmented in-services for medication policies 2. All med techs will have completed a competency checklist, signed by RN, prior to independently administering medication. RN and Nursing support team with review medication administration program weekly, during clinical meetings and recorded in minutes. 3. Weekly 4. RN and ED will be responsible to see that the corrections are completed/monitored

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 6 sampled resident (# 6) whose orders were reviewed. Findings include, but are not limited to: Resident 6 was admitted to the facility in 2021 with diagnoses including dementia, Type II Diabetes and delirium. 1. Resident 6 had a physician's order, dated 03/04/22, to check CBG (blood sugar level) before meals and at HS (before bed). Resident 6's 03/01/22 through 04/11/22 MAR and progress notes from 03/01/22 through 04/11/22 revealed the staff either did not check CBGs or checked CBGs after meals on multiple occasions. 2. Resident 6 had a physician's order, dated 03/04/22, to administer Levemir (insulin to treat diabetes) 13 units two times daily. Resident 6's 03/01/22 through 04/11/22 MAR revealed on 03/22/22, the insulin was not administered as prescribed without documented explanation. 3. Resident 6 had a physician's order, dated 03/04/22, to check monthly vital signs on the second of each month and fax MD (Doctor of Medicine) and notify RN if blood pressure top number greater than 160 or less than 100, or blood pressure bottom number greater than 100 or less than 50, pulse greater than 100 or less than 50. Resident 6's 03/01/22 through 04/11/22 MAR revealed there was no documented evidence monthly vital signs were checked on the MAR. 4. Resident 6's 03/01/22 through 04/11/22 MAR and progress notes from 03/01/22 through 04/11/22 revealed the following medications were not administered as prescribed due to the medications not being available: * Risperidone (a medication to treat to irritability) 0.25 mg two times daily, not administered on six occasions; * Metformin (a medication to treat Type II Diabetes) 1000 mg two times daily, not administered on one occasion; and * Pioglitazone (a medication to treat Type II Diabetes) 30 mg daily, not administered on two occasions. On 04/13/22 and 04/14/22, the physician orders, the MARs and progress notes were reviewed with Staff 2 (ED) and Staff 4 (RCC). They acknowledged the findings.

1. During 90-day review RN will specify if care staff can assist with treatment orders and will review TAR with Pharmacy Rep. 2. Med techs will hold onto all treatments and ointments, when care staff apply these treatments the med techs will administer to care staff, confirm application and then document in the TAR. 3. Weekly 4. RCC and RN will be responsible to see that the corrections are complete/monitored.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters and staff instruction for 3 of 5 sampled residents (#s 4, 5 and 6) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 2018 with diagnoses including dementia. a. Resident 5's 04/01/22 through 04/11/22 MAR was reviewed and revealed the following scheduled treatment: * Nystatin 100,000 unit cream to apply two times daily; and * Secura Protective 10 % cream to apply two times daily. The MAR did not provide information including location for the administration of topical cream. b. Resident 5's 04/01/22 through 04/11/22 MAR was reviewed and revealed the following: * Lorazepam 0.5 mg as needed for anxiety. The MAR did not provide information including how often the medication needed to be administered. c. Resident 5's 04/01/22 through 04/11/22 MAR was reviewed and revealed the following: * Multiple blanks on the MAR. Resident specific parameters and accurate documentation of the MAR were discussed with Staff 2 (ED) and Staff 3 (RN) on 04/12/22 and 04/13/22. Staff acknowledged the findings. 2. Resident 6 was admitted to the facility in 2021 with diagnoses including dementia and Type II Diabetes. a. Resident 6's 03/01/22 through 04/11/22 MARs and physician orders were reviewed and revealed the following: * The resident received scheduled insulin two times daily; and * Trulicity (an injectable medication to treat Type II Diabetes) weekly. There were no parameters for holding the insulin administration for low blood sugar levels and there was no direction for staff when to notify the physician of high blood sugars . b. Resident 6's 03/01/22 through 04/11/22 MARs were reviewed and revealed the following: * Multiple blanks on the MAR. c. Resident 6's 04/01/22 through 04/11/22 MAR and 04/04/22 - 04/12/22 progress notes were reviewed and revealed the following: * 04/10/22 - Staff 9 (MT) signed on the MAR that she administered Levemir insulin when Staff 25 (MT) administered the insulin injection; and * 04/11/22 - Staff 18 (MT/Trainer) signed on the MAR that she administered Levemir insulin when Staff 3 (RN) administered the insulin injection. d. Resident 6's 03/01/22 through 04/11/22 MARs and physician orders were reviewed and revealed the following: * Physician's order, dated 03/04/22, to check CBG before meals and at HS (before bed); and * The MAR indicated staff signed they checked CBGs at 9:00 am when breakfast was served at 8:00 am. The need to ensure accurate documentation of the MAR was discussed with Staff 2 (ED) and Staff 4 (RCC) on 04/12/22 and 04/14/22. Staff acknowledged the findings. 3. Resident 4's 03/01/22 through 04/11/22 MARs and physician orders were reviewed and revealed the following: * The 04/09/22 dose of Carbidopa/Levo 100 mg tab to be administered at 1:30 pm was blank on the MAR; * The 04/09/22 dose of Quetiapine 12.5 mg tab to be administered at 1:00 pm was blank on the MAR; and * The 03/17/22 dose of Atropine drops to be administered at 9:00 pm was blank on the MAR. The need to ensure accurate documentation of the MAR was discussed with Staff 2 (ED) and Staff 4 (RCC) on 04/13/22. They acknowledged the findings.

1. RN will over see medication administration system, med tech trainings, administration and orders. All med techs will have completed a competency checklist, signed by RN. There will be doucmented in-services for medication policies 2. All med techs will have completed a competency checklist, signed by RN, prior to independently administering medication. RN and Nursing support team with review medication administration program weekly, during clinical meetings and recorded in minutes. 3. Weekly 4. RN and ED will be responsible to see that the corrections are completed/monitored

Based on interview and record review, it was determined the facility failed to ensure an accurate TAR, with clear instructions to staff, accurate documentation and specific treatment orders by a legally-recognized practitioner for 2 of 2 sampled residents (#s 3 and 4) who received wound care. Findings include, but are not limited to: Resident 3 was admitted to the facility in 2017 with diagnoses including dementia and anxiety. 1. Resident 3's clinical record noted the following: Resident 3's MAR included a section for treatment by med techs noting "wash area with wound wash or similar product. Approximate edges with moist cotton swab. Apply steri-strips  or transparent dressing - leave in place until loose. Check daily..." There was no specific instruction or physician's order as to what kind of wound wash to use, how to approximate wound edges, or how to determine when to use steri-strips. Progress notes and an incident report documented that on 04/07/22 Resident 3 was discovered with a skin tear. There was no documentation of wound care provided on the MAR/TAR. The need to ensure the facility obtained signed physicians orders for treatments, included clear instructions for staff and documented treatments administered on the MAR/TAR was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 04/14/22. They acknowledged the findings. 2. Resident 4's clinical record noted the following: Progress notes and incident reports reviewed from 01/10/22 through 04/10/22 revealed the following: * 03/18/22:  an abrasion to the resident's head was covered with a bandage; and * 04/03/22: "wound care" to a skin tear to the left knee was performed by the Med Tech. There was no documentation of wound care provided on the MAR/TAR. The need to ensure treatments administered were documented on the MAR/TAR was discussed with Staff 2 (ED) and Staff 3 (RN) on 04/13/22. They acknowledged the findings.

1. During 90-day review RN will specify if care staff can assist with treatment orders and will review TAR with Pharmacy Rep. 2. Med techs will hold onto all treatments and ointments, when care staff apply these treatments the med techs will administer to care staff, confirm application and then document in the TAR. 3. Weekly 4. RCC and RN will be responsible to see that the corrections are complete/monitored.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months from fire drills. Findings include, but are not limited to: On 04/11/2022, at the survey entrance, fire drill and fire and life safety records for the past six months were requested. On 04/12/22, at 12:00 pm, Staff 2 (Executive Director) reported the facility was unable to provide the requested  records. The facility lacked documented evidence of the following required components: * Fire drills were being conducted every other month. * The escape route used; * Number of occupants evacuated; * Problems encountered and comments related to residents who resisted or failed to participate in the drills; and * Documentation the facility provided fire and life safety instruction to staff on alternate months from fire drills.   The need to ensure fire drills were conducted every other month and required components were documented and life safety instruction was provided to staff on alternate months was discussed with Staff 2 on 04/12/22 at 12:10 pm. She acknowledged the findings.

1. Maintanence Director conducted a fire drill on 4/12/22 and Elopment drill on 4/27/22 with appropriate documentation. Next month He will be providing life and fire safety education at our all-staff meeting on 5/19/22. This will also be documented and signed by attendees and put in their employee files. 2. Maintanence director will continue this pattern, fire drill every other month, elopment drill quarterly and fire and life safety education on opposing months of fire drills. Appropriate documentation will be kept with Maintanence Director. 3. Fire drill every other month and life and fire safety education on the months we do not do Fire drills. 4. Maintanence Director

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code and residents were provided fire and life safety training annually. Findings include, but are not limited to: On 04/11/2022, at survey entrance,  fire drill and life safety records for the past six months were requested. On 04/12/22, at 12:00 pm, Staff 2 (ED) reported that the facility was unable to provide the requested records. The facility lacked documented evidence of the following required Components: * Alternate escape routes were used during fire drills; * Documentation of problems encountered with residents who declined to participate, and changes made to ensure the evacuation standard was met; and * Documented evidence residents were provided training and instruction on fire and life safety annually. The need to ensure alternate escape routes were used during fire drills, documentation of problems encountered with residents who declined to participate, and changes made to ensure the evacuation standard was met, and residents were instructed on fire and life safety procedures annually, was discussed with Staff 2 on 04/12/22 at 12:10 pm. She acknowledged the findings.

1. Documentation for fire drills will be maintained by Maintanence Director. Fire drills will happen every other month. Documentation will include escape routes used, problems with residents who decline to participate and any changes made to ensure evacuation standards were met. On 5/19/22 we will be inviting all employees and residents to attend a fire and life safety meeting at 2:30pm. Documentation will include information covered and attendees. 2. Proper documentation and Reminders for drills and education will be maintained using TELS and/or hard copies of Documentation in fire and life safety binder. 3. Monthly and annually. Drills and education will be monitored monthly, resident education will be evaluated annually and set to occur again May 2023. 4. Maintanence Director

Based on interview and record review, it was determined the facility failed to re-instruct residents at least annually in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire, in accordance with the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to: On 08/09/22 Staff 7 (Maintenance Director) confirmed the facility had not provided annual fire and life safety training to residents. The need to ensure fire and life safety instruction was provided to residents at least annually as required by the OFC was reviewed with Staff 2 (Executive Director) and Staff 30 (Executive Director) on 08/10/22. They acknowledged the findings.

1) POA's for each resident has signed and been educated on Fire and Life Safety for their loved one who resides in the community at time of move-in. Residents who have lived here her beyond 1-year has been send Fire and Life Safety document to review and sign. 2) When resident is edging toward their 1-year mark, their POA will be sent Fire and Life Safety document to review and sign to be returned. 3) annually 4) Business Office Manager and Maintanence Director

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit. Findings include, but are not limited to: The interior of the building was toured on 04/11/22. The following issues were noted: * During the initial tour on 04/11/22, two of four kitchenettes had unlocked cupboards with peri-care cleanser and cleaning chemicals accessible to the residents; * On 04/11/22, the need to ensure all toxic materials were maintained in locked storage was discussed with Staff 2 (ED). The findings were acknowledged at that time. During a follow-up inspection on 04/12/22, one of four kitchenettes continued to have unlocked cupboards with cleaning chemicals accessible to the residents.  The need to ensure all toxic materials were maintained in locked storage was discussed with Staff 24 (CG); and * During another follow-up inspection on 04/13/22, two of four kitchenettes continued to have unlocked cupboards with cleaning chemicals accessible to the residents. This included one kitchenette that did not previously have chemicals accessible to the residents. The need to ensure all toxic materials were maintained in locked storage was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN) on 04/13/22. They acknowledged the findings.

1. All Chemicals and other toxic substances will be removed from kitchenettes and placed in locked drawers, cupboards or custodial closet 2. During Morning walk through's Maintanence Department will check cabinets for improperly stored chemicals, Notify care staff and immediately return them to the locked custodial closet if needed. A sign will be placed on cabinet under the sink in Kitchenette's indicating that chemicals may not be stored anywhere except the locked custodial closet and/or other locked cabinets and/or drawers. 3. Daily 4. Maintanence Director

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were stored in a locked storage unit. This is a repeat citation. Findings include, but are not limited to:   The interior of the building was toured on 08/09/22. The following issues were noted:   * The Burnside kitchenette had a one gallon container of antibacterial hand soap in an unlocked cabinet underneath the sink; * The Hawthorne kitchenette had a spray bottle of multipurpose cleaner in an unlocked cabinet underneath the sink; and * The Bistro had six different cleaning chemicals in an unlocked cabinet underneath the sink. All of these chemicals were accessible by residents. The need to ensure all toxic materials were kept in locked storage was discussed with Staff 2 (ED) and Staff 30 (ED) on 08/10/22. They acknowledged the findings.

1) All chemicals and hand soaps have been removed from unlocked cabinets and placed in locked custodial closets. 2) Notices have been posted inside unlocked cabinets under sinks in kitchenettes and Bistro notifying staff not to store chemicals or soaps in these cabinets and to only store in locked custodial closets when not using them. 3) Daily 4) Maintenance Director and Housekeeping

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to: Observations of the facility on 04/11/22 through 04/12/22 showed the following areas were in need of cleaning and/or repair: In the central room: * Entrance doors to the MCC showed damaged paint; * Couch with stains and food debris around cushions; and * Stained chair near the beauty salon. On the 100 Hall: * Stained couch cushions; * Odors noted near rooms 101 and 102; * Gouged cabinet door near the custodian room; * Two large sideboards with damaged tops and exposed wood; and * Laundry room ceiling vent clogged with dust. On the 200 Hall: * Stained chair near courtyard exit; * Baseboards damaged and with dust build up; * Two large sideboards with damaged tops and exposed wood; and * Laundry room ceiling vent clogged with dust. On the 300 Hall: * Couch stained and with food debris; * Damaged corner baseboard near the shared bathroom; * Two large sideboards with damaged tops and exposed wood; and * Laundry room ceiling vent clogged with dust. On the 400 Hall: * A black table with peeling paint near the courtyard entrance; * Room 403 with wall and door damage; * Room 405 with damaged door seal; * Two large sideboards with damaged tops and exposed wood; and * Laundry room ceiling vent clogged with dust. The need to ensure the environment was kept clean and in good repair was discussed with Staff 2 (ED) and Staff 7 (Maintenance Director) on 04/12/22, they acknowledged the findings.

1. *Doors to MCC will be repainted *A punch list has been created of furniture that is stained. Summit (who we use to clean our carpets) will be coming in to remove stains from all furniture of concern. * Odor between 101 and 102 has been addressed by thoroughly cleaning 101, 102 and their bathrooms. * All cabinets in neightborhoods have been examined and repairs will be made by Maintanence Director * All vents have been cleaned * Baseboards in neighborhoods and all other common areas have been wiped clean of dust and build up by housekeeping team * Damaged corner baseboard near shared bathroom in 300 has been repaired * Black table in 400 will be completed by Activities team and sealed to protect from paint peeling. * 403 wall and door damage will be repaired during room flip in the month of may * 405 damaged door seal will be repaired 2. Policies and procedures as it pertains to environment have been reviewed with new Maintanence Director who will maintain the environment of our community, including and not limited to: Clean base boards, repair all wall damages, door and baseboard damages, Clean all vents in laundry rooms, identify and address odors and ensure counters and table tops are in good repair and addressing any gouges or chips. 3. These issues and needed repairs will be evaluated weekly 4. Maintanence director will be responsible to see these corrections are completed/monitored.

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 limited to: Refer to C 150, C 152, C 155, C 231, C 240, C 420, C 422, C 510 and C 513.

See plan of correction for C150, C152, C155, C231, C240, C420, C422, C510 and C513

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C240, C422 and C510.

Refer to C240, C422 and C510

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

Refer to C 240

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 sampled newly hired staff (#s 19 and 21) completed all required pre-service orientation prior to performing any job duties, 2 of 2 sampled long term staff (#s 14 and 17) had completed the required 16 hours of annual in-service training, and 4 of 4 sampled staff (#s 9, 12, 13 and 14) lacked competency training in the area of medication administration prior to providing care and services independently.  Findings include, but are not limited to: Staff training records were reviewed on 04/13/22. The following deficiencies were identified: 1. Staff 21 (CG) was hired 03/03/22. There was no documented evidence s/he had completed the following elements of the required pre-service orientation prior to performing any job duties: * Resident rights and values of CBC care; * Fire safety and emergency procedures; and * Written job description. Staff 19 (Cook) was hired 07/27/21. There was no documented evidence s/he had completed the following elements of the required pre-service orientation prior to performing any job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Standard precautions for infection control; and * Fire safety and emergency procedures. 2.  Staff 17 (CG) was hired on 12/01/20 and Staff 14 (CG and MT) was hired on 03/19/21. There was no documented evidence that either staff member had completed the required 16 hours of annual training related to provisions of care in CBC, including six hours related to dementia care. The facility's failure to ensure staff completed all required training in a timely manner and prior to working independently was discussed with Staff 2 (ED) and Staff 18 (Trainer) on 04/13/22. They acknowledged the findings. 3.  Staff 12 (MT) hired 02/25/22, Staff 9 (CG/MT) hired 11/01/21, Staff 13 (MT) hired 07/23/20 and Staff 14 (MT) hired 03/19/21 had no documented evidence they had demonstrated competency within 30 days of hire or prior to working independently with residents in the area of medication administration. During an interview on 04/12/22 at 3:08 pm, Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN) verified there was no documented evidence of medication administration competencies for staff. At approximately 5:44 pm the survey team requested a plan to ensure MT's had received observation and training prior to administering medications. A plan was submitted and accepted on 04/13/22. The need to ensure the facility had a system which included documented methods to determine competency of direct care staff through evaluation, observation or written testing, was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN) on 04/13/22.  Staff acknowledged the findings.

1. All Employee files have been audited and Employees with any missing documentation have been notified. Missing documents have been being collected by our Trainer and has also added a section to each direct care staffs folder for coninuted education. 2. Each week our staff have an opportunity to earn continued education hours and each month there is a required video assigned to staff on Relias that will cover the 6-hours of dementia specific training. Competency checklists for both Cargegivers and Med techs will be located in their employee files and completed prior to them working without a trainer. Upon completion of Orientation and training, all documentation regarding life and fire safety, job descriptions, abuse and neglect reporting, residents rights and standard infection control will be found in each employee file. 3. Monthly 4. The trainer will be in charge of communicating with staff regarding continued education and training and the Business office manager will be in charge of Orientation paperwork such as job desciption, residents rights, background checks, etc.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly hired staff (#s 31 and 32) completed all required pre-service orientation and/or dementia training prior to performing job duties. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed on 08/09/22 and 08/10/22. The following deficiencies were identified: 1. Staff 31 (CG) was hired 07/15/22. There was no documented evidence she had completed the following elements of the required pre-service orientation and dementia training prior to starting job duties: * Resident rights and values of community-based care; * Abuse reporting requirements; * How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and * Use of supportive devices with restraining qualities in memory care communities. 2. Staff 32 (CG) was hired 07/13/22. There was no documented evidence she had completed the following elements of the required pre-service dementia training prior to starting job duties: * Use of supportive devices with restraining qualities in memory care communities. The need to ensure newly hired staff completed pre-service orientation and dementia training prior to starting job duties was discussed with Staff 2 (ED) and Staff 30 (ED) on 08/10/22. They acknowledged the findings.

1) All missing documents from identified staff members have been collected 2) During Orientation and Training, all required training documents will be collected prior to working independently 3) With each new hire 4) Business Office Manager and ED

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities.  Findings include, but are not limited to: Refer to C 260, C 262, C 270, C 280, C 282, C 290, C 300, C 303, C 310 and C 315.

Refer to C260, C262, C270, C280, C282, C290, C300, C303, C310 and C315

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

Refer to C260, C270 and C280

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

Refer to C 260 and C 280

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 3 of 3 sampled residents (#s 1, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to: Resident 1, 3, and 4's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and that their service plans had been individualized to reflect the following: * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations needed to participate; * Identification of activities for behavioral interventions; and * There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities. On 04/13/22, the lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN). They acknowledged the findings.

1. Activities team will be take all of our residents life stories, current knowledge and assesments and create a more formal assesment for each residents that will touch base on the following categories: Current abilities and skills, emotional/social needs and patterns, physical abilities and limitations, adaptions needed to participate, identification of activities for behavioral interventions and how oftern staff and how staff need to assist resident to/with activities. 2. Activities team will keep their own collection of activities assesments for each resident. Once complete they will also add this information into the residents service plan on PCC. This will be done at admission, and will be refreshed when quarterly service plan updates occurs as well. 3. At admission and then every 90-days 4. Life Enrichment Director

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to: The MCC was toured on 04/11/22. Residents rooms 101, 109, 112, 208, 212B, 303, 305, 405, 406, 409 and 411A lacked individualized identification markers required to assist residents in recognizing their rooms. The need to ensure each resident room was identified for the resident was reviewed with Staff 2 (ED) on 04/13/22. She acknowledged the rooms lacking identification.

1. Resident rooms 101, 109, 112, 208, 212B, 303, 405, 409 & 411A have all since had their shadow boxes filled with personal identifiers. Resident rooms 305 and 406 are vacant. 2. Upon move in, Activites team will prepare the new residents shadow box with something that helps indentify that resident. 3. This will need to be corrected or evaluated whenever we have new move-ins and/or move outs 4. Life Enrichment Director

Based on observations, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to Z 142, Z 162, C 240, C 260 and C 280.

Refer to Z 142, Z 162, C 240, C 260 and C 280

The findings of the re-licensure survey conducted 04/11/22 through 04/14/22 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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 04/14/22, conducted 08/09/22 through 08/10/22, 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 for Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 04/14/22, conducted 12/12/22 through 12/13/22, 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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 04/14/22, conducted 04/05/23, 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.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents in accordance with OAR 411-054-0025(4) per complaint that staff are not wearing masks in the facility. Based on interview, observation and record review, it was confirmed the facility failed to exercise reasonable precautions regarding infection control.  Findings include: During onsite visit on 02/08//22, Compliance Specialist (CS) observed Staff #1-16 do one or more of the following while the facility is under an Executive Order (EO) for having Covid positive residents: *Not wear eye protection in patient care area. *Wear mask under their nose. *Pull mask down to their chin. *Take their mask off completely in patient care areas. *Pull mask down to talk to residents. Staff were observed passing out eye protection to direct care staff while CS was onsite.  Staff #4 and Staff #13 were both observed numerous times by CS with their mask down and eye protection flipped up and when they saw this CS they would move both items into the correct position. CS was not screened for Covid-19 prior to entering patient care area of facility or at any time during onsite visit.  Review of facility screening logs revealed not all staff had screened in prior to their shift. During separate interviews with Staff #1-16, the following was stated: *It is so hot in here [stated while s/he was fanning him/herself with eye protection] *We should be wearing eye protection, but I forgot.   *Compliance with masking and eye protection is challenging. The above findings were discussed with Staff #1, who was in agreement.