Bonaventure of Gresham Memory Care

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 maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility’s kitchen on 06/18/25 at 9:45 am revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease was visible on, around or underneath the following: * Baseboards and floors throughout the kitchen; * Walls throughout the kitchen; * Ceilings throughout the kitchen, including fire sprinkler heads, vents and light fixtures; * Shelves on prep, serving, and cooking stations; * Water and gas lines throughout the kitchen; * Table legs of prep tables, rolling carts and storage racks in the kitchen and walk-in refrigerator; * Handles, doors/ fronts and sides of upright refrigerator units and appliances; * Ice maker interior cartridge; * Drain in soda dispenser; * Interior casing of can opener; * Plate holder wells, interior and exterior walls; * Floors in dry storage room; and * Floors, walls and door of janitor’s closet. b. The following kitchen items required repair or replacement: * Ice maker door had hard water tracks from the frame of the door down the right side of the machine; * Microwave oven had chipped and melted enamel on the interior door and frame; * Spatulas were stained and burned/ gouged; * Wall material was cracked along the doorway to the janitor’s closet; * Cutting boards on prep and service lines were scored and stained and uncleanable; * A gap in the ceiling tiles above the stove revealed cardboard filler between the end of the tiles and the wall; and * Multiple plastic food serving pans on the storage rack were broken. c. Poor infection control practices observed, but not limited to: * Kitchen staff failed to perform hand hygiene consistently between dirty and clean tasks; * Beard restraints were not used by staff; * Plated desserts in one of the free-standing refrigerators were not covered; * Silverware on preset tables were not wrapped; * Salad bar refrigerator did not have a thermometer; * Open boxes and an open bag of food were observed in the dry storage room; and * Multiple containers of salad dressing in the dry storage room were dented. Observations of the MCC kitchenette on 06/18/25 at 10:40 am revealed the following: a. An accumulation of food spills, splatters, food debris, dirt, dust, and/or black matter was visible on, around or underneath the following: * Floors throughout the kitchenette, including floor drain under hot food station; * Inside the microwave oven; * Stove and oven; and * Exterior and interior walls of all cabinetries. b. The following kitchen items required repair or replacement: * Oven drawer; and * Cutting board on service line. c. Poor infection control practices observed, but not limited to: * A spoon was stored in the brown sugar container in the refrigerator with the handle in contact with food product. A kitchen walkthrough was completed with Staff 1 (ED), Staff 2 (MCC Director) and Staff 3 (Regional Kitchen Manager) on 06/18/25 at 1:05 pm. The areas that did not meet the rules were discussed with Staff 1, Staff 2 and Staff 3. They acknowledged the findings.

The memory care director will assign cleaning tasks to the MCU staff based on the areas of concern that are listed in this citation. The health and wellness director will complete a walkthrough once those tasks are done to ensure completion. The ED and MCD will review all items that need to be repaired and will put in work orders to have the repairs completed. If an item is beyond repair, a new one will be purchased. An inservice will take place in regard to proper infection control practices. The memory care staff will follow a AM/PM cleaning task list to ensure that all appliances, storage, and furniture remain clean and in good repair. The MCD will routinely monitor all employees during their shift for proper infection control practices. If any issues are noted, the MCD will follow-up with prompt retraining. Evaluation will take place weekly during a 1:1 meeting between the executive director and the memory care director. The health and wellness director and the memory care director.

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 411-054-0030 (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 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 staff (#5) who prepared food had active food handler's certificates. Findings include, but are not limited to: On 06/18/25, employee records were requested and reviewed to ensure staff had active food handler's cards. The food handler's card for Staff 5 (Cook) was expired effective 05/31/25. On 06/17/25 at 12:40 pm, Staff 1 (ED) confirmed Staff 5 was currently on shift and preparing food but did not have an active food handler’s card. The need to ensure staff who prepared food had active food handler’s certificates was discussed with Staff 1 on 06/18/25 at 1:43 pm. She acknowledged the findings.

Staff #5 completed the training to renew her food handlers certificate. Upon onboarding, the AED will ensure that all pre-service requirements are completed prior to providing service. The AED and HWD will routinely review the staff training matrix to ensure that all certifications are up to date. The staff training certificate matrix will be reviewed weekly during the 1:1 meeting between the ED and the AED/HWD. Executive director, assistance executive director, and the health and wellness director.

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

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240 and C370.

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

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

See C240 POC

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 411-057-0140(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 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 staff (#5) who prepared food had active food handler's certificates. Findings include, but are not limited to: On 06/18/25, employee records were requested and reviewed to ensure staff had active food handler's cards. The food handler's card for Staff 5 (Cook) was expired effective 05/31/25. On 06/17/25 at 12:40 pm, Staff 1 (ED) confirmed Staff 5 was currently on shift and preparing food but did not have an active food handler’s card. The need to ensure staff who prepared food had active food handler’s certificates was discussed with Staff 1 on 06/18/25 at 1:43 pm. She acknowledged the findings.

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

OAR 411-054-0105 (1) Inspections and Investigations (Amended 12/15/21)(1) The facility must cooperate with Division personnel in inspections, complaint investigations, planning for resident care, application procedures, and other necessary activities. (a) Records must be made available to the Division upon request. Division personnel must have access to all resident and facility records and may conduct private interviews with residents. Failure to comply with this requirement shall result in regulatory action. (b) The State Long Term Care Ombudsman must have access to all resident and facility records that relate to an investigation. Certified Ombudsman volunteers may have access to facility records that relate to an investigation and access to resident records with written permission from the resident or guardian. (c) The State Fire Marshal or authorized representative must be permitted access to the facility and records pertinent to resident evacuation and fire safety.(d) The Oregon Health Authority and appropriate Local Public Health Authority must be permitted access to the facility and records pertinent to investigation of illness or outbreak, as authorized by law.

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 C240.

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

Based on observation and interview, the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240.

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

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 05/23/25.  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 CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health HS: Hours of sleep LPN: Licensed Practical Nurse MT:            Medication Technician or Med Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse SP: Service plan SPT: Service Planning Team TAR: Treatment Administration Record

Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. Findings include, but are not limited to: Observations during the survey from 08/13/24 to 08/15/24, showed a lack of scheduled and unscheduled activities provided for residents living in the memory care community. The Activity Calendar for August 2024 was provided and indicated scheduled activities for each day of the week. The activities scheduled according to the calendar for 08/13/24, 08/14/24, and 08/15/24 included the following: 08/13/24 * 11:00 am - Beach ball toss; and * 1:30 pm - Water coloring. Observations at 11:00 am and 1:30 pm were made and the activities did not take place. 08/14/24 * 10:30 am - Daily chronicles and whiteboard games; * 11:00 am - Music & Movement; and * 2:00 pm - Bingo. Observations at 10:30 am, 11:00 am, and 2:00 pm were made and the activities did not take place. 08/15/24 * 11:00 am - Mini golf; and * 2:00 pm - Games on the back patio. Observations at 11:00 am and 2:00 pm were made and the activities did not take place. During the survey, multiple residents were observed throughout the day sitting at the dining room tables, sleeping and/or watching TV in the living room. The need to ensure the facility provided a daily program of social and recreational activities that were based on individual and group interests, and physical, mental, and psychosocial needs was discussed with Staff 2 (Health and Wellness Director) and Staff 3 (Memory Care Director) on 08/15/24. They acknowledged the findings.

-New AD hired 9/1/24 -Activity calendar for Sept underway -in-service will be conducted with SCU staff on their role in the activity program -SCU matrix up and running to guide staff on their daily routine including activities -MCD to randomly observe 2 activities on dayshift/2 activities on eve to assure they are occurring per calendar/schedule MCD/Executive Director

2. Resident 1 was admitted to the facility in 01/2024 with diagnoses including dementia and failure to thrive. Review of the resident's quarterly evaluation dated 07/15/24 and progress notes dated 05/13/24 through 08/13/24 identified the following: The resident experienced two significant changes of condition in 07/2024, due to a right hip fracture and an admission to hospice, respectively. The facility lacked documented evidence Resident 1's evaluation was reviewed with any updates documented when the significant changes in condition were identified. During an interview at 12:45 pm on 08/15/24, Staff 5 (RN) acknowledged the lack of documented changes of condition updates in the quarterly evaluation. The need to ensure updates were documented each time a resident had a significant change in condition was discussed with Staff 2 (Health and Wellness Director) and Staff 3 (Memory Care Director) on 08/15/24 at 4:15 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to complete a resident evaluation before the resident moved into the facility that contained all required elements for 1 of 1 sampled resident (#3), ensure updates were documented each time a resident had a significant change in condition for 2 of 2 sampled residents (#s 1 and 2), and changes were dated and initialed for 1 of 2 sampled residents (#2) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 05/2024 with diagnoses including dementia and depression. The facility was asked to provide a copy of Resident 3's initial evaluation. During an interview on 08/14/24, Staff 3 (Memory Care Director) indicated she remembered doing the move-in evaluation but could not provide the document. No further documentation was provided that included Resident 3's move-in evaluation. The need to ensure resident evaluations were completed before the resident moved into the facility that addressed all required elements was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), Staff 3 and Staff 8 (Co-director of Health Services and Quality Assurance) on 08/16/24 at 10:00 am. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 01/2024 with diagnoses including dementia and metabolic encephalopathy. The facility was asked to provide a copy of Resident 2's quarterly evaluation. During an interview on 08/13/24, Staff 3 (Memory Care Director) indicated the most recent evaluation was the initial move-in evaluation dated 01/24/24. She stated handwritten changes were made since move-in but was unable to recall the date of those changes. No further documentation was provided. Review of the resident's evaluation dated 01/24/24 and progress notes dated 05/13/24 through 08/13/24 identified the following: The resident experienced two significant changes of condition in 06/2024 and 07/2024, due to weight loss. The facility lacked documented evidence Resident 2's evaluation was reviewed with any updates documented when the significant changes in condition were identified. The need to ensure changes to the evaluation were dated and initialed and updates were documented each time a resident had a significant change in condition was discussed with Staff 2 (Health and Wellness Director) and Staff 3 (Memory Care Director) on 08/15/24 at 4:30 pm. They acknowledged the findings.

-Residents with move in dates from July 1st to current will be audited to verify completion of pre-move in evals.  Service plans/evals for Res # 2 will be updated to reflect current care and service needs.   Res #1 has since passed away. -Re-education with MCD on pre-move in eval , use of TCP's and process for manually updates a residents service plan to include date change was made, was completed to assure understanding. -ED or MCD to review new move in charts within 48hrs to verify completion of pre-move in eval. ED or MCD to conduct daily review of resident chart notes assuring TCP's are initiated for applicable changes of condition and/or manual changes made to service plans are dated.

Based on interview and record review, it was determined the facility failed to complete a resident evaluation before the resident moved into the facility that contained all required elements for 1 of 1 sampled resident (#6) and ensure updates were documented each time a resident had a significant change in condition for 2 of 2 sampled residents (#s 4 and 5) whose evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 4 moved into the MCC in 11/2023 with diagnoses including dementia. Review of the resident's combined quarterly evaluation and resident service plan dated 01/30/25, temporary care plans (TCP's) and charting notes dated 10/11/24 through 02/04/25 identified the following: Resident 4 lacked documented evidence an evaluation was completed and/or documented with updates after the following significant changes of condition: * 10/11/24 - Pressure ulcer on left heel; * 11/14/24 - Pressure ulcer on right heel; * 12/16/24 - Weight loss of 19 pounds or 10.21% of total body weight; and * 01/10/25 - Pressure ulcer on right buttocks. The need to ensure evaluations were completed and documented with updates each time a resident experienced a significant change in condition was reviewed with Staff 3 (Memory Care Director) on 02/11/25 at 12:38 pm. She acknowledged the findings. 2. Resident 5 moved into the MCC in 08/2024 with diagnoses including unspecified dementia. Review of the resident's combined quarterly evaluation and resident service plan dated 11/26/24, temporary care plans (TCP's) and charting notes dated 11/01/24 through 01/29/25 identified the following: The resident experienced a significant change of condition on 01/05/2025, due to a left sacral (hip) fracture. Progress notes identified the resident had increased pain, had multiple falls with emergency room visits, unsteady gait and balance when walking, and was encouraged to use a wheelchair. On 01/13/25, Staff 3 (Memory Care Director) made a handwritten note on the 11/26/24 "Resident Service Plan" (which is a combined evaluation and service planning document) that noted "admitted to hospice, call hospice for all urgent issues. Do not call 911!" The 11/26/24 evaluation lacked information on the residents current status and condition in the following areas: * Fall interventions including 30 minute checks and LED light strips on the floor; * Ambulation status including escorts to meals and activities; * Oxygen status; * Assistive devices including the use of side rails; and * Pain status. During an interview on 02/10/25 at 3:00 pm, Staff 2 (Health and Wellness Director) and Staff 23 (Regional RN) stated their system for evaluating and care planning included a "change" option for updating the evaluation and care planning following significant changes of condition. Staff 2 and 23 confirmed Resident 5 did not have a "change" evaluation completed following the significant change of condition. There was no documented evidence Resident 5's evaluation was reviewed with any updates documented when the significant change in condition was identified. The need to ensure updates were documented each time a resident had a significant change in condition was discussed with Staff 2, Staff 3, and Staff 23 on 02/11/25 at 2:06 pm. They acknowledged the findings. 3. Resident 6 moved into the MCC in 01/2025 with diagnoses including anxiety and agitation. Resident 6's initial evaluation dated 01/01/25 was reviewed and lacked the following required care elements: * Gender identity; * Pronouns; * Transfer ability; * Nutrition habits; * Fall risk and history; * Elopement risk and history; and * Alcohol and drug use. The need to ensure resident evaluations addressed all required care elements was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), Staff 3 (Memory Care Director) and Staff 23 (Regional RN) on 02/11/25 at 2:06 pm. They acknowledged the findings .

Residents with move in dates from January 1st to current will be audited to verify completion of pre-move in evals. Service plans/evals for Res #4 and Res #5 will be updated to reflect current care and service needs. Re-education with MCD on full completion of pre-move in evaluation as well as what additional needs are to be included.   Re-education with MCD and Nurse completed in regard to short term change of condition vs. long term change of condtion processes. The MCD will fill out the required "change of condition tracking" on a daily basis.  This will ensure that all changes are addressed in a timely and appropriate manner to meet the health and safety needs of all residents in our care. The MCD and HWD will review new movein charts within 48 hours to verify completion of the pre-move in evaluation.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services, and were implemented for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 01/2024 with diagnoses including dementia and failure to thrive. Observations of the resident, interviews with staff, review of the resident's most recent service plan, dated 07/15/24, and temporary care plans showed the service plan did not provide clear direction to staff or was not reflective of the resident's needs in the following areas: * Use of outside provider; * Use and assistance with wheelchair; * Current ability to express needs; * Side rail safety instructions; * Alternating pressure mattress instructions; * Assistance needed with glasses; * Ability to adequately communicate needs; * Meal assistance instructions; * Frequency of offering nectar thick fluids; * Use of oxygen; and * Skin issues. The need to ensure service plans were reflective of resident's current care needs and provided clear direction to staff was discussed with Staff 2 (Health and Wellness Director) and Staff 3 (Memory Care Director) on 08/15/24. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 01/2024 with diagnoses including dementia and urinary retention. Observations of the resident, interviews with staff, review of the resident's most recent service plan, dated 01/24/24, showed the service plan did not provide clear direction to staff or was not reflective of the resident's needs in the following areas: * Level of assistance required during evacuation; * Behaviors including resistance to showering, fire drills, evacuation; and * Showers require three-person assistance. Interviews with staff, temporary care plans dated 07/25/24, and MARs dated 07/26/24 to 08/13/24 showed the service plan was not implemented in the following areas: * "Give acetaminophen first to rule out pain"; and * "If that is not effective give seroquel". The need to ensure service plans were reflective of resident's current care needs, provided clear direction to staff, and services were implemented was discussed with Staff 2 (Health and Wellness Director) and Staff 3 (Memory Care Director) at 4:30 pm on 08/15/24. They acknowledged the findings.

Res 1 passed away Res 2-Resident's needs have been re-evaluated and SP update will be completed. Audit of remaining residents service plans will be completed to assure accuracy. MCD with ED oversight will assure SP accuracy through at least weekly review of progress notes, outside provider visit notes, occurrence documentation to assure accuracy.   MCD will assure service plan updates are made in conjunction with the service plan review schedule of initial, 30 day and 90 day or with a change of condition MCD/Executive Director

2. Resident 4 moved into the MCC in 11/2023 with diagnoses including dementia. The resident's current service plan, dated 01/30/25, and temporary care plans (TCP's) were reviewed, observations were made, and interviews were conducted. The following was identified: The service plan was not reflective of the resident's needs and did not provide clear instruction to staff in the following areas: * Repositioning assistance needed and use of a wedge; * Use of side rails including the risks, benefits and safety instructions; * Incontinent care including frequent incontinence checks and resident specific instruction; and * Aspiration precautions including swabbing the resident's mouth after all meals. The need to ensure service plans were reflective of resident needs and provided clear direction to staff was discussed with Staff 3 (Memory Care Director) on 02/11/25 at 12:38 pm. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services for 2 of 2 sampled residents (#s 4 and 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 5 moved into the MCC in 08/2024 with diagnoses including unspecified dementia. Observations of the resident, interviews with staff, review of the resident's most recent service plan, dated 11/26/24, and temporary care plans (TCP's) showed the service plan did not provide clear direction to staff and/or was not reflective of the resident's needs in the following areas: * Use of side rails including the risks, benefits and safety instructions; * Fall interventions including: 30-minute safety checks during the night and  light strips placed on the resident's unit floor; * Use of oxygen and instructions for maintaining the supplies; and * Frequency for toileting assistance. The need to ensure service plans were reflective of resident's current care needs and provided clear direction to staff was discussed with Staff 3 (Memory Care Director) on 02/10/25 at 3:30 pm. She acknowledged the findings.

Res #4 and Res #5- Resident's needs have been re-evaluated and SP update will be completed. Audit of remaining residents service plans will be completed to assure accuracy. MCD with ED oversight will assure service plans accurately reflect the scheduled/unscheduled needs of the resident through at least weekly review of progress notes, outside provider visit notes, and occurrence documentation. MCD will assure service plan updates are made in conjunction with the service plan review schedule of initial, 30 day and 90 day or with a change of condition Memory Care Director with oversight from the memory care licensed administrator and executive director.

2. Resident 1 moved into the facility in 01/2024 with diagnoses including dementia and failure to thrive. The current service plan dated 07/15/24, temporary care plans, and progress notes dated 05/13/24 through 08/13/24 were reviewed. Observations and interviews with staff were completed between 08/13/24 and 08/15/24. The facility failed to determine what action or intervention was 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 conditions: * 07/15/24 - Return to facility from skilled nursing facility; * 07/22/24 - Return from hospital after right hip fracture; * 07/31/24 - Diet change to nectar thick liquids; and * 08/06/24 - New wound to left hip. The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and were monitored at least weekly through resolution was discussed with Staff 2 (Health and Wellness Director) and Staff 3 (Memory Care Director) at 4:15 pm on 08/15/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short term changes of condition, communicated actions and interventions to staff on each shift, and monitored the change of condition at least weekly until resolved for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 01/2024 with diagnoses including dementia and metabolic encephalopathy. The current service plan dated 01/24/24, temporary care plans, and progress notes dated 05/13/24 through 08/13/24 were reviewed. Observations and interviews with staff were completed between 08/13/24 and 08/15/24. The facility failed to determine what action or intervention was 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 conditions: * 05/13/24 - Hospital visit for dehydration; * 05/13/24 - New diagnosis, clostridium difficile; * 05/13/24 - Antibiotic for clostridium difficile; * 06/07/24 - Hospital visit for resident self-destructed catheter when s/he bit through tubing; * 06/21/24 - Hospital visit for resident dislodged catheter; * 06/27/24 - Significant weight loss (6.9%); * 07/08/24 - Significant weight loss (10.9%); * 07/09/24 - Hospital visit for resident dislodged catheter; * 07/25/24 - Increased agitation; and * 08/09/24 - Hospital visit for a urinary tract infection and new antibiotic. The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and were monitored at least weekly through resolution was discussed with Staff 2 (Health and Wellness Director) and Staff 3 (Memory Care Director) at 4:30 pm on 08/15/24. They acknowledged the findings.

Res #1-passed away.  Res #2:  Resident service plan updated with most recent changes and direction for staff to follows for monitoring. Re-education provided on the community alert charting and Temporary Care Plan processes with MT and CG staff to assure understanding. MCD/Nurse will assure routine audits of resident care related documentation to assure timely application of the alert charting and TCP processes. Daily/weekly audits MCD/Nurse

2. Resident 4 moved into the MCC in 11/2023 with diagnoses including dementia. Resident 4's current service plan, dated 01/30/25, temporary care plans (TCP's), and charting notes dated 10/30/24 through 02/04/25 were reviewed, observations were made, and interviews were conducted. The following was identified: * 10/11/24 - Pressure ulcer on left heel; * 11/14/24 - Pressure ulcer on right heel; * 11/26/24 - New treatment: hydrocortisone cream; * 12/11/24 - Skin tear on back of left hand; * 12/10/24 - Six-month weight loss of 19 pounds or 10.21% of total body weight; and * 01/14/24 - Antibiotics for infected pressure ulcer on buttocks. There was no documented evidence resident-specific actions or interventions were determined for the above noted changes of condition, the actions or interventions were communicated on all shifts, and/or changes were monitored through resolution. On 02/10/25 at 2:24 pm, Staff 3 (Memory Care Director) confirmed there was no additional documentation for the above referenced changes of condition. The need to ensure actions or interventions were determined for changes of condition, the actions or interventions were communicated on all shifts, and/or changes were monitored through resolution was reviewed with Staff 3 on 02/11/25 at 12:38 pm. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short term changes of condition, communicated actions and interventions to staff on each shift, and monitored the change of condition at least weekly until resolved for 2 of 2 sampled residents (#s 4 and 5) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 5 moved into the MCC in 08/2024 with diagnoses including unspecified dementia. The current service plan dated 11/26/24, temporary care plans (TCP's), and charting notes dated 11/01/24 through 01/29/25 were reviewed. Observations and interviews with staff were conducted during the survey. Observations of the resident during the survey identified the resident had a skin tear on the back of his/her right arm, near the elbow area that was covered with a bandage. The facility failed to determine what action or intervention was 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 conditions: * 01/07/25 - Skin tear on the right arm; * 01/11/25 - Found on floor; * 01/27/25 - Cut on finger; and * 01/29/25 - Bruise on the left side. The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and were monitored at least weekly through resolution was discussed with Staff 3 (Memory Care Director) on 02/10/25 at 3:30 pm. She acknowledged the findings.

Res #4 and Res #5- Resident's needs have been re-evaluated and SP update will be completed. Re-education provided to the facility nurse and MCD in regard to change of condition timeline (48 hours) requirements. Re-education provided about short-term change of condition vs. long-term change of condition to assure understanding of differing processes. MCD/Nurse will assure routine aduits of resident care related documentation to assure timely application of the alert charting, TCP, and service plan update processes.  Daily/weekly audits. MCD/Nurse

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a timely assessment that documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 1 and 2), who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 01/2024 with diagnoses including dementia and failure to thrive. Progress notes dated 05/13/24 to 08/13/24, and a change of condition evaluations dated 07/24/24 and 08/02/24, respectively , were reviewed and the following was identified: Resident 1 experienced a fall with a right hip fracture and was hospitalized for surgery from 07/17/24 to 07/22/24. The resident was admitted to hospice on 07/30/24. The hip fracture, surgery, and hospice admit constituted significant changes of condition for which an RN assessment was required. During an interview at 12:45 pm on 08/15/24, Staff 5 (RN) acknowledged the RN assessments were completed timely, but lacked documentation of the resident status and interventions made as a result of the assessments. The need to ensure an RN assessment for residents who experienced significant changes of condition included documentation of resident status and interventions made as a result of the assessment was discussed with Staff 2 (Health and Wellness Director) and Staff 3 (Memory Care Director) on 08/15/24 at 4:15 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 01/2024 with diagnoses including dementia. A review of the resident's clinical record, including progress notes dated 05/13/24 through 08/13/24 and weight records dated 02/25/24 through 08/13/24, was completed, and staff were interviewed. The following was identified: The resident's weight was recorded as follows: * 02/25/24 - 203.5 pounds; * 05/13/24 - 232 pounds; * 06/09/24 - 216 pounds; * 07/08/24 - 193 pounds; * 08/11/24 - 199 pounds; and * 08/13/24 - 202.5 pounds (taken during survey). From 05/13/24 to 06/09/24 the resident lost 16 pounds or 6.9% of his/her body weight which constituted a severe weight loss for which a significant change of condition was required. From 06/09/24 to 07/08/24 the resident further lost 23.5 pounds or 10.9% of his/her body weight which constituted a severe weight loss for which a significant change of condition assessment was required. The resident was observed at two meals. S/he consumed 100% of the meals. She/he was observed to require no assistance for feeding. During an interview at 11:43 am on 08/15/24, Staff 3 (Memory Care Director) confirmed an RN assessment had not been completed until 6/27/24. She stated no additional RN assessment had been completed since 06/27/24. The need to ensure a timely RN assessment was completed which included resident status, findings, and interventions made as a result of the assessment for all significant changes of condition was discussed with Staff 2 (Health and Wellness Director) and Staff 3 (Memory Care Director) on 08/15/24 at 4:30 pm.

Res #1-passed away.  Res #2:  Resident re-evaluated by the nurse with documented interventions for most recent changes of condition. Reviewed with RN the rules and associated community policy re routine review for changes of condition and expected assessments to include interventions as applicable with weekly f/u to assure understanding. RN will conduct weekly audits of resident care related documentation to assure timely awareness of changes and timely documentation of assessment and plan of care. Nurse

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a timely assessment that documented findings, resident status, and interventions made as a result of the assessment and ensure the licensed nurse participated on the Service Planning Team, or reviewed the service plan with date and signature within 48 hours for 2 of 2 sampled residents (#s 4 and 5), who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 4 moved into the MCC in 11/2023 with diagnoses including dementia. A review of the resident's record, including Charting Notes and RN change of condition assessments, dated 10/30/24 through 02/04/25, were reviewed and the following was identified: a. Resident 4 was identified with a new pressure sore on 10/11/24. An RN assessment for this significant change of condition was documented on 11/29/24. b. On 12/10/24, the resident was identified to weigh 167 pounds which constituted a significant weight loss of 19 pounds or 10.21% of his/her total body weight from 06/2024 through 12/2024. An RN assessment was completed for this significant change of condition on 12/16/24. On 02/11/25 at 11:42 am, Staff 23 (Regional RN) confirmed the lack of a timely RN assessment for the significant changes of condition identified above. The need to ensure an RN assessment was completed timely was reviewed with Staff 3 (Memory Care Director) on 02/11/24 at 12:38 pm. She acknowledged the findings. 2. Resident 5 moved into the MCC in 08/2024 with diagnoses including unspecified dementia. Charting notes dated 11/01/24 through 01/29/25, and a service plan dated 11/26/24 were reviewed during the survey. The following was identified: Resident 5 experienced a pattern of falls on the following dates: * 01/02/25 - Injury fall and was sent to the emergency room and diagnosed with a hip contusion; * 01/04/25 - Injury fall and was sent to the emergency room. On 01/05/25 s/he was diagnosed with a left sacral (hip) fracture; * 01/08/25 - Two falls on the same day and went to the emergency room; and * 01/11/25 - Found on floor fall. Resident 5 experienced a decline in ADL ability, gait imbalance and intermittently started using a wheelchair. The pattern of falls, fall resulting in a left hip fracture on 01/05/25, and a decline in ADL ability and health status constituted a significant change of condition for which an RN assessment was required. Additionally, there was no documented evidence the RN participated on the Service Planning Team or reviewed the service plan within 48 hours following the significant change of condition. During an in-person interview with Staff 2 (Health and Wellness Director) and a  phone interview with Staff 23 (Regional RN) on 02/10/25 at 3:00 pm it was reported a nursing assessment was completed on 01/13/25. Staff 2 and Staff 23 acknowledged the RN assessment was not completed timely. The need to ensure an RN assessment for residents who experienced significant changes of condition was completed timely and the licensed nurse participated on the Service Planning Team, or reviewed the service plan with date and signature within 48 hours was discussed with Staff 1 (ED), Staff 2, Staff 3 (Memory Care Director) and Staff 23 on 02/11/25 at 2:06 pm. They acknowledged the findings.

See individual POC statements for applicable C tags.Residents # 4 and # 5: Residents have been re-evaluated by the nurse with documented interventions for most recent changes of condition. Re-education provided to the facility nurse in regard to change of condition timeline (48 hours) requirements. Re-education provided about short-term change of condition vs. long-term change of condition to assure understanding of differing processes. The facility Nurse will assure routine aduits of resident care related documentation to assure timely application of the alert charting, TCP, and service plan update processes.  Daily/weekly audits. Facility Nurse

Based on observation and interview, it was determined the facility failed to maintain effective infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for multiple sampled and unsampled residents. Findings include, but are not limited to: Observations made from 08/13/24 to 08/15/24 revealed the following: a. Observations of lunch service on 08/13/24 and 08/14/24 revealed multiple universal caregivers served food to residents without donning a protective barrier over potentially contaminated clothing. b. Staff 16 (CG) and Staff 18 (CG) were observed walking out of a resident's room with single use gloves at 2:58 pm on 08/13/24. They were observed walking into Resident 2's room, assisting the resident with transferring and touching multiple surfaces with the soiled gloves, without performing hand hygiene. c. Staff were observed delivering meals, beverages, desserts, and snacks to residents' rooms without covering the food or beverage to protect from contamination. d. Staff were observed serving meals and beverages, touching residents, and their chairs and/or wheelchairs, removing dirty dishes and providing meal assist to an unsampled resident without consistently changing their gloves or performing hand washing in between clean and dirty tasks. The need to maintain effective infection prevention and control protocols was discussed with Staff 2 (Health and Wellness Director) and Staff 3 (Memory Care Director) at 4:30 pm on 08/15/24. They acknowledged the findings.

Aprons were obtained for use during meal service. Re-education provided to CG staff on proper attire during meal service, proper handwashing and glove changing (what is clean/what is dirty) procedures as well as proper food service and storage requirements. MCD will provide random supervision for 1 meal a day for 3/week for the next 30 days to assure adherence to protocols of meal service. MCD

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were administered only after documented, non-pharmacological interventions were tried with ineffective results for 1 of 1 sampled resident (#2) who had an order for PRN psychotropic medications. Findings include, but are not limited to: Resident 2 was admitted to the facility in 01/2024 with diagnoses including dementia and metabolic encephalopathy. The resident's 07/01/24 to 08/13/24 MARs and progress notes and current physician orders were reviewed. The following was identified: The resident had an order for quetiapine, administer one tablet by mouth twice a day as needed for anxiety. The MARs indicated staff administered the PRN medication on twenty-four occasions from 07/01/24 to 08/13/24. There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the PRN psychotropic medication. The need to ensure there was documentation that staff administered PRN psychotropic medications only after attempting non-pharmacological interventions with ineffective results was discussed with Staff 2 (Health and Wellness Director) and Staff 3 (Memory Care Director) on 08/15/24 at 4:30 pm. They acknowledged the findings.

Res 2 MAR reviewed to assure all PRN Psychotropic orders had description of behaviors and interventions for staff to attempt prior to use. Review of remaining residents orders to verify presence of required documentation for behaviors and interventions. Re-education will be provided to MT staff on rules and associated community procedures for PRN Psychoactive medications. MCD/Nurse will assure ongoing auditing daily for new orders and weekly for ongoing orders to assure proper directions are present and being followed MCD/Nurse

Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, and failed to instruct caregivers on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (# 1) who used a supportive device with restraining qualities. Findings include, but are not limited to: Resident 1 moved into the facility in 01/2024 with diagnoses including dementia and failure to thrive. Observations of the resident and interviews with staff indicated the resident had a half-length side rail on both sides of his/her bed. The side rail was in good repair and flush with the mattress. The resident's service plan, dated 07/15/24, failed to document other less restrictive alternatives were evaluated prior to the use of the device and to instruct caregivers on the correct use and precautions related to the use of the side rails. Staff reported the resident was primarily bedbound and received the hospital bed with side rails from the hospice provider. On 08/15/24 at 12:40 pm, Staff 5 (RN) confirmed an assessment of the side rail was not completed prior to survey entry. The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and were included in the resident's service plan was discussed with Staff on 08/15/24. They acknowledged the findings.

-Res 1 has passed away.   -A review of remaining residents using supportive devices was conducted to verify completion of the necessary evaluations. When the facility is requesting devices, the assessment/ less restrictive alternatives/ risk factors will be discussed with resident/POA prior to use of device. Facility will evaluate/discuss less restrictive alternatives and risk factors as soon as able for devices that are found already installed by outside entities or family. -MCD and RN will review weekly for any new devices and monthly to assure evaluations are current and that Service plans are up to date. Weekly/Monthly MCD/Nurse

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care and to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to the following: The facility was licensed as a Residential Care Facility (RCF) with a capacity of 24 beds. a. During the acuity interview on 08/13/24 with Staff 3 (Memory Care Director) and Staff 5 (RN) the following care needs were identified: * The facility had a census of 22 residents; * Five residents required two-person assistance for transfers; * Four residents required cueing/re-direction during meals and/or one-on-one assistance with feeding; and * Eleven residents were reported to require high levels of caregiving assistance due to hospice, exit-seeking/wandering, need for frequent safety checks, and/or due to fall risk. b. During the survey, the facility staffing policy or a tool to determine number of caregiving staff needed to provide scheduled and unscheduled residents' care needs was requested by survey. Staff 1 (ED) stated the facility used the service plan points generated to determine staffing levels. The facility acuity-based staffing tool (ABST) was reviewed during the survey. The facility ABST for multiple sampled and unsampled residents had not been added to, reviewed , or updated as required. Therefore, the tool could not be used to determine an appropriate staffing plan. c. The current posted staffing plan on 08/13/24 was as follows: * Day shift - Two caregivers and one MA; * Swing shift - Two caregivers and one MA; and * Night shift - One caregiver and one MA. d. Review of the Uniform Disclosure Statement for the Memory Care Community was provided on 08/13/24 and indicated the facility used one universal worker on day and swing shift. During an interview on 08/15/24 at 11:55 am, Staff 3 confirmed all of the caregivers are considered universal workers. In addition to providing care and services to residents, they are expected to help with laundry, serve food and clean up after meals, and assist with activities "when activity staff are not available." e. Observations and interviews conducted from 08/13/24 to 08/15/24 revealed the following: * One care staff in the kitchen plated the meals and one staff assisted the residents in the dining room. For lunch service on 08/14/24, a caregiver provided feeding assistance to an unsampled resident while also serving drinks and meals and cleaning up. In addition, the caregiver provided cues to Resident 3 to stay at the table and frequent assistance and re-direction to an unsampled resident banging on the table and yelling intermittently throughout the meal. This caregiver also left the dining room two times during the meal leaving no care staff in the dining room for resident's needs. * Multiple residents were observed throughout the day sitting at the dining room tables, sleeping, and/or watching TV in the living room. (Refer to C 242) * During an interview on 08/14/24 at 2:35 pm, Staff 21 (MA) confirmed she will "step in and help out with activities." She also indicated, "I'll be honest, I think we could use one more caregiver because we have a lot going on here, especially on swing shift." * During an interview on 08/13/24 at 1:05 pm, Staff 20 (MA) stated it is often two caregivers and one MA on the floor, but some residents require more than two people to help. At those times, there is no one left on the floor. * During an interview on 8/15/24 at 11:58 am, Staff 3 stated she needed to update the service plan for Resident 2 to reflect his/her need for three-person assistance for showering. * During an interview on 08/15/24 at 11:55 am, Staff 3 indicated the facility had been given the "okay" to schedule a third staff a few days a week but had not been "given the budget" to have three caregivers consistently for day and swing shift. The facility lacked a sufficient number of direct care staff to meet the scheduled and unscheduled needs and fire evacuation standards of the multiple residents who required the assistance of two care staff for transfers and had high levels of care needs. A written plan to address the insufficient staffing was requested from Staff 1, Staff 2 (Health and Wellness Director), Staff 3, Staff 8 (Co-director of Health Services and Quality Assurance), and Staff 9 (Regional RN) at 3:48 pm on 08/15/24, and was received by the survey team at 11:47 am on 08/16/24. The need to increase staffing levels to compensate for increased staff duties and unscheduled resident needs for all shifts was discussed with Staff 1, Staff 2, Staff 3, and Staff 8 on 08/16/24. They acknowledged the findings.

Staffing mandate 3/3/2 -Job fair completed with 1 successful hire -MCD and ED will review staffing and scheduling needs daily during daily stand up meeting. MCD will re-evaluate resident needs and accuracy of ABST tool for correlating staffing needs weekly with the ED. MCD and ED will assure monthly staffing schedules are archived for future reference.

Based on interview, and record review, it was determined the facility failed to ensure all residents were entered into the staffing tool, to use the results of the tool to develop and routinely update the facility's staffing plan, and to update the acuity-based staffing tool (ABST) no less than quarterly or following a significant change of condition for 2 of 2 sampled residents (#s 1 and 2) and multiple unsampled residents whose ABST data was reviewed. Findings include, but are not limited to: As of survey entrance on 08/13/24, the following was identified: * Nine residents, including one sampled resident (#3), had not been entered into the ABST used by the facility; * The most recent updates were completed on 02/15/24 for four residents, including Resident 1, who experienced significant changes of condition after 02/15/24; * Resident 2, who experienced significant changes of condition, was last updated on 02/15/24 and indicated as "Incomplete"; and * Seven residents had been entered into the facility's ABST, but were not indicated on the resident roster provided upon entrance. During an interview on 08/15/24 with Staff 1 (ED), she acknowledged the facility's ABST did not have all of the current residents entered and several of the residents were no longer in the building. She indicated the facility used the service plan points, rather than their ABST tool, to determine staffing levels. The need to ensure the facility used an ABST which met the regulation was discussed with Staff 1 (ED) on 08/16/24. She acknowledged the facility failed to ensure a staffing tool was in place and fully implemented , with all residents accurately entered and updated prior to move-in, no less than quarterly , or with a significant change of condition.

ABST tool is now currently reflecting all SCU residents and their individual care needs. MCD has received additional training on updating and maintaining the ABST tool to assure understanding. MCD will provide weekly oversight of the ABST tool to assure new move ins/changes of condition/move outs are reflected timely on the ABST tool as well as quarterly updates with service plans. Weekly/Quarterly MCD/Executive Director

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 re-instructed, at least annually. Findings include, but are not limited to: Fire and life safety records were requested and reviewed with Staff 3 (Memory Care Director) on 08/15/24 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 1 (ED), Staff 2 (Health and Wellness Director), Staff 3, and Staff 8 (Codirector of Health Services and Quality Assurance) on 08/16/24 at 10:00 am. They acknowledged the findings.

Fire life safety training was provided to residents. MCD and Executive Director have reviewed regulations to assure understanding. MCD will review new residents charts within 48 hours of move in to assure initial training has been provided and will audit quarterly to assure annual training for all residents has been completed (see above) MCD/Executive Director

Based on observation and interview, it was determined the facility failed to ensure  all interior materials and surfaces were kept clean and in good repair and failed to ensure the facility was free from unpleasant odors. Findings include, but are not limited to: The interior of the building was toured at 9:25 am on 08/13/24. The following was identified: * There was a pervasive, unpleasant odor in the facility corridor of rooms one through eight that did not dissipate during the survey; * There were multiple scratches and scuffs throughout the floor of the dining room; and * The carpet was stained in multiple areas in the corridors. The need to ensure the facility was maintained clean and free from unpleasant odors was discussed with Staff 2 (Health and Wellness Director) and Staff 3 (Memory Care Director) on 08/15/24. They acknowledged the findings.

All areas of needed minor repair have been corrected. Carpet cleaning has been completed for noted findings Residents with rooms with odors have been evaluated to assure effective toileting plan is in place. MCD will conduct daily walkthroughs of  common areas and resident apts for 30 days then resume at least weekly to oversee ongoing compliance. daily for 30 days then weekly MCD/Executive Director

Based on interview and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple sampled and unsampled residents. Findings include, but are not limited to: During an interview on 08/13/24 at 2:40 pm, Staff 2 (Health and Wellness Director) confirmed the majority of the residents did not have keys to their units. Review of Resident 1, 2, and 3's service plans indicated the residents were "not issued a key." The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1 (ED), Staff 2, Staff 3 (Memory Care Director), and Staff 8 (Codirector of Health Services and Quality Assurance) on 08/16/24 at 10:00 am. No additional information was provided.

Sampled Res #2 & #3 were evaluated for ability to use a key and service plans updated with applicable information.  Res #1 has passed away. All remaining residents will be issued a key, if not, family member/POA  to be issued a key and documented in Service plan. An audit of remaining residents and their service plans was conducted to review which residents or associated family had a key and who still needs a key. Those who do not have a key will be given one to meet this rule. Ongoing key audits will take place in conjunction with the service plan update process, quarterly, or with a significant change of condition. MCD/Executive Director

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 295, C 360, C 361, C 422, and C 513.

See individual POC statements for affected C tags.

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

See individual POC statements for applicable C tags.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 10, 12, 17 and 22) completed all pre-service orientation and dementia training prior to beginning their job responsibilities and 1 of 1 long term, non-direct care staff (#19) completed required annual infectious disease training. Findings include, but are not limited to: Staff training records were reviewed with Staff 8 (Co-director of Health Services and Quality Assurance)  at 1:40 pm on 08/15/24. The following was identified: a. There was no documented evidence Staff 10 (Activities), hired 07/25/24, Staff 12 (Caregiver), hired 06/14/24, and Staff 17 (Caregiver), hired 06/07/24, and Staff 22 (MA), hired 05/13/24, completed required pre-service orientation training prior to beginning job duties in one or more of the following areas: * Written job description; * Infectious disease prevention; * Pre-service dementia care; and * Home and Community-Based Services. b. There was no documented evidence Staff 19 (Housekeeping), hired 09/24/22, completed annual infectious disease training. The need to ensure newly hired staff complete all pre-service orientation and pre-service dementia training prior to beginning job duties and completed required infectious disease training annually was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), Staff 3 (Memory Care Director) and Staff 8 on 08/16/24 at 10:00 am. They acknowledged the findings.

Late preservice training is completed for sampled staff. Audit of remaining staff completed to verify compliance with initial and annual training for infectious disease to include non-direct care staff (all staff). MCD/Executive Director will complete audits of all new and current employee training files for completion of the orientation process and annual infection trainings. To be completed twice monthly to maintain ongoing compliance. Upon completion of the orientation process and twice monthly thereafter. MCD and Office manager/Wellness director/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 242, C 252, C 260, C 270, C 280, C 330, and C 340.

See individual POC statements for applicable C tags.

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 243, C 252, C 260, C 270, C 280.

See individual POC statements for applicable C tags.

Based on interview and record review, it was determined the facility failed to ensure physical injuries of unknown cause were reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse for 1 of 1 resident (#5) who was reviewed with an injury of unknown cause. Findings include, but are not limited to: Resident 5 moved into the MCC in 08/2024 with diagnoses including unspecified dementia. Progress notes and resident occurrence reports (the document used by the facility to investigate injuries) dated 11/07/2024 through 02/07/2025 were reviewed during the survey. The following was identified: On 01/29/25 hospice noted a bruise on the residents left side. Facility staff transcribed the provider's note into the resident's progress notes. There was no documented evidence the facility conducted an immediate investigation to determine the physical injury was not the result of abuse. On 02/11/25, Staff 3 (Memory Care Director) provided survey with a copy of a self report to the local Adult Protective Services office. The need to ensure the facility had a system in place to identify and immediately investigate physical injuries of unknown cause to rule out suspected abuse or report to the local SPD office was discussed with Staff 3 on 02/10/25 at 3:30 pm. She acknowledged the findings.

All existing reportable incidents have been reported to APS. MCD will complete a daily review of outside provider notes, chart notes, and occurence reports for any reportable findings. If any are noted, the incident(s) will be reported per APS reporting guidelines and in a timely manner to ensure ongoing compliance. The review of outside provider notes, chart notes, and occurrence reports will occur on a daily basis. Memory Care Director with oversight from the memory care licensed administrator and executive director.

Based on observation, interview, and record review, it was determined the facility failed to provide services to assist residents in activities of daily living for 1 of 1 sampled resident (#4) who required staff assistance. Findings include, but are not limited to: Resident 4 moved into the MCC in 11/2023 with diagnoses including dementia. The resident was observed to use a wheelchair and was in common areas throughout the survey. The resident's service plan dated 01/30/25 and temporary care plans dated 10/11/24 through 02/04/25 were reviewed and instructed staff to perform the following ADL's: * Routinely take resident to room to use a portable urinal; * Check briefs frequently for bladder and bowel incontinence; and * Rotate every two hours with use of wedge. Observations made on 02/07/25, 02/10/25, and 02/11/25 identified the following: * Staff were not observed to check Resident 4 for incontinence; * Staff were not observed to bring the resident to his/her room to use a portable urinal; and * Staff were not observed to rotate or reposition the resident with the use of a wedge. On 02/11/25 at 10:30 am, Staff 13 (CG) stated Resident 4 did not use his/her portable urinal and was checked for incontinence two to six times per shift. Staff 13 stated the resident was only rotated or repositioned while in bed. On 02/11/25 at 11:53 am, the above was reviewed and discussed with Staff 2 (Health and Wellness Director) and Staff 23 (Regional RN). An updated TSP was developed and was communicated to staff. The need to ensure services were provided to assist residents in activities of daily living was reviewed with Staff 3 (Memory Care Director) on 02/11/25 at 12:38 pm. She acknowledged the findings.

Staff have been inserviced on the necessity to read updated and new service plans and execute associated supports. Staff will read new and current service plans to ensure current supports are followed. The memory care director will provide random supervision of care for different residents 3x a week. This will be done over the next 60 days to ensure that all support needs are being followed per resident service plans. Memory Care Director

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 252, C 260, C270, C 280

Refer to updated plan of correction for associated tags. C 252, C 260, C270, and C280 All applicable staff will carry out this plan of correction and will do so moving forward to assure ongoing complaince. Daily/Weekly Memory Care Director with oversight from the memory care licensed administrator and executive director.

The findings of the re-licensure survey, conducted 08/13/24 through 08/16/24, 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 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit survey to the re-licensure survey of 08/13/24, conducted on 02/07/25 and 02/10/25 through 02/11/25 are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 08/16/24, conducted 04/09/25 through 04/10/25, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure kitchen practice and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.  Findings include, but are not limited to: On 04/09/24 at 11:15 am, the facility was observed to need cleaning in the following areas: a. Food spills, splatters, debris, grease, black/brown matter and/or dust was observed on or underneath the following: * Shelves below the steam table, grill and prep counters;   * Hood vents above the stove, grill and deep fat fryer;   * Sides and front of the oven, grill and deep fat fryer; * Floor under the grill, stove, steamer and plate warmer; * Exterior of food bins; and * Floor drains near steamer and under single sink prep counter. Other findings included: * Raw hamburgers and hot dogs stored in the small refrigerator next to steam table were not tightly closed on the bottom shelf creating the potential for cross contamination; * Tubs of ice cream stored in "cold containers" on the counter outside of kitchen between the dining rooms were left uncovered in a high traffic area; *Improper glove use by not washing hands between gloves changes; and   * Lack of beard restraints. The areas of concern were discussed with Staff 1 (Executive Director) and Staff 2 (Administrator) on 04/09/24. The findings were acknowledged.

Kitchen Cleanliness: 1. As of 4/15, all areas in need of cleaning have been addressed. All drains were inspected and cleaned by 4/20. 2. A bi-monthly cleaning schedule for all ceiling vents, the sides of oven, grill and deep fryer has been created. The cleaning of the floor under the grill, the steam table and a wipe down of the exterior of the food bins have been added to  the daily cleaning task list. The  An in-service was done 4/9 for all kitchen staff to address covering the ice cream at all times, beard and hair restraints and open food items in all refrigerators. Memory Care Director has added weekly drain inspection/cleaning to Memory Care Weekly cleaning task list. Dining Services Manager to audit monthly as part of Dining Services Quality Assurance audit. 3. The Dining Services manager or designee will inspect cleanliness of all areas on a weekly basis by adding to the weekly One-on-One agenda with ED. 4. Dining Services Manager or designee will be responsible for ensuring corrections are completed/monitored. Improper Glove Usage: 1. Immediate re-training was done for employees observed using gloves improperly.  All staff in-service completed on April 25th for proper glove usage/handwashing.  Proper glove usage/handwashing educational signs were posted in the kitchen (Assited Living and Memory Care) 4/9/24. 2. Ongoing staff training on proper glove usage/handwashing to be done as needed based on new staff. Dining Services Manager to audit monthly as part of Dining Services Quality Assurance Audit. 3. Dining Services Manager or designee will observe for proper glove usage/handwashing on a daily basis in addition to Monthly Quality Assurance audits.  Will inspect weekly for the next 6 weeks as part of Weekly one on One. 4. Dining Services Manager or designee will be responsible for ensuring corrections are completed/monitored.

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.

Kitchen Cleanliness: 1. As of 4/15, all areas in need of cleaning have been addressed. All drains were inspected and cleaned by 4/20. 2. A bi-monthly cleaning schedule for all ceiling vents, the sides of oven, grill and deep fryer has been created. The cleaning of the floor under the grill, the steam table and a wipe down of the exterior of the food bins have been added to  the daily cleaning task list. The  An in-service was done 4/9 for all kitchen staff to address covering the ice cream at all times, beard and hair restraints and open food items in all refrigerators. Memory Care Director has added weekly drain inspection/cleaning to Memory Care Weekly cleaning task list. Dining Services Manager to audit monthly as part of Dining Services Quality Assurance audit. 3. The Dining Services manager or designee will inspect cleanliness of all areas on a weekly basis by adding to the weekly One-on-One agenda with ED. 4. Dining Services Manager or designee will be responsible for ensuring corrections are completed/monitored. Improper Glove Usage: 1. Immediate re-training was done for employees observed using gloves improperly.  All staff in-service completed on April 25th for proper glove usage/handwashing.  Proper glove usage/handwashing educational signs were posted in the kitchen 4/9/24. 2. Ongoing staff training on proper glove usage/handwashing to be done as needed based on new staff. Dining Services Manager to audit monthly as part of Dining Services Quality Assurance Audit. 3. Dining Services Manager or designee will observe for proper glove usage/handwashing on a daily basis in addition to Monthly Quality Assurance audits.  Will inspect weekly for the next 6 weeks as part of Weekly one on One. 4. Dining Services Manager or designee will be responsible for ensuring corrections are completed/monitored.

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

The findings of the re-visit to the kitchen inspection of 04/09/24, conducted on 06/25/24, are documented in this report. The facility was found in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and appropriate measures were in place to prevent cross contamination in accordance with the Food Sanitation Rules OARs 333-150-0000. Finding include, but are not limited to: On 04/25/23 at 11:10 am, the facility kitchen was observed to need cleaning in the following areas: * The ceiling throughout the entire kitchen, including the dish washing room and the dry storage had vents and fire alarms with significant accumulation of dust/debris; and * The areas of the ceiling surrounding the vents and alarms also had significant build up of dust. The following observations conducted on 04/25/23 during the kitchen tour revealed improper cross contamination measures: * Dishwashing staff failed to wash hands between dirty and clean activities in the dish room; and was observed to towel dry some dishes rather than allow to air dry;   * During the noon meal service one staff serving lunch left the steam table with gloves on and went to the walk in refrigerator/freezer to obtain frozen meat patty which was then placed in the microwave to be cooked. The staff returned to the steam table to continue serving food without washing hands and changing gloves; and *The same staff was observed to return to the walk in refrigerator/freezer with gloves on and retrieve additional food to be prepared on the grill without washing hands and changing gloves. The concerns were discussed with Staff 1 (Cook), Staff 2 (Executive Director) and Staff 3 (Assistant Executive Director) on 04/25/23. The findings were acknowledged.

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

The findings of the kitchen inspection, conducted on 04/25/23, 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 re-visit to the survey of 04/25/23, conducted on 07/06/23, 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 OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review it was confirmed that the facility/staff failed to immediately notify the local Department office of any incident of abuse or suspected abuse. Findings include the following: During an unannounced site visit on 10/26/2022 Compliance Specialist (CS) reviewed Resident Occurrence Reports for the month of September. CS found five occurrences of unwitnessed falls with injury that had not been reported to the local department. In an interview with Staff #1 (S1) it was stated that they were unaware that unwitnessed falls with injury for residents that are unreliable narrators are reportable instances. Facility Plan of Correction: S1 will ensure that all reportable instances are reported to APS moving forward.

Based on observation and record review it was confirmed that the facility failed to have a daily program of social and recreational activities. Findings include the following: During an unannounced site visit on 10/26/2022 Compliance Specialist (CS) reviewed facilities Uniform Disclosure Statement (UDS) revealed that the facility will have six hours of structured activities every day. CS reviewed posted activities schedule dated 10/21/22 which did not include six hours of activities. CS received a copy of the facility's weekly activity calendar for October 2022; calendar did not consistently have six hours of structured activities scheduled. CS observed the posted sign dated same day as visit which did not have any activities listed. CS observed activities began for the day at 1 o'clock, but there did not appear to be a schedule or structure for the activities occurring.

Based on interview and record review it was confirmed that the facility failed to have qualified direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include the following: During an unannounced site visit on 10/26/2022 Compliance Specialist (CS) reviewed facilities staffing schedule for September and October 2022, payroll details for 09/25-10/01/2022 and facility Acuity Based Staffing Tool (ABST). September and October schedules had several instances where facility was not staffed to facility ABST. Facility payroll details for 09/25-10/01/2022 also indicate facility was staffing under ABST at the time. In an interview with Staff #1 (S1) it was stated that they took a state training and afterwards realized that the facility was not staffing appropriately for their ABST and then increased their staffing to match their ABST. Based on interview and record review it was confirmed that the facility failed to have qualified direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include the following: During an unannounced site visit on 10/26/2022 Compliance Specialist (CS) reviewed facilities staffing schedule for September and October 2022, payroll details for 09/25-10/01/2022 and facility Acuity Based Staffing Tool (ABST). September and October schedules had several instances where facility was not staffed to facility ABST. Facility payroll details for 09/25-10/01/2022 also indicate facility was staffing under ABST at the time. In an interview with Staff #1 (S1) it was stated that they took a state training and afterwards realized that the facility was not staffing appropriately for their ABST and then increased their staffing to match their ABST. Facility Plan of Correction: The facility is currently staffing to their ABST, staffing was corrected by the time of CS ' s time of site visit.

Based on interview and record review it was confirmed that the facility failed to have a training program that includes methods to determine competency of direct care staff. Findings include the following: During an unannounced site visit on 10/26/2022 CS requested demonstrated competencies and checklists for Staff # 4 - Staff #6 (S4-S6). All three staff had completed Caregiver ADL Skills Checklist and Observations completed, but two of three were not completed within 30 days of hire. 2 of 3 required Medication Technician Skills Checklists and Observations of Medication Pass and 1 of 2 was not completed within 30 days of hire. In an interview with Staff #1 (S1) it was stated that they had been working on the training program and was working through staff files to ensure checklists were completed and working through completing checklists for all staff including more senior staff members. S1 acknowledged findings. Facility Plan of Correction: S1 is in the process of working through staff files and ensuring that their training files are complete and implementing a training program the meets state requirements.

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 10/26/2022.  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