Bonaventure of Gresham Memory Care

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.

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:

Based on 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.

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.

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.

This Rule is not met as evidenced by:

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.

This Rule is not met as evidenced by:
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.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:
Based on observation, interview, and record review, 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.

This Rule is not met as evidenced by:
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.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to 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.

This Rule is not met as evidenced by:

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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthHS: Hours of sleepLPN: Licensed Practical NurseMT: Medication Technician or Med TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered NurseSP: Service planSPT: Service Planning TeamTAR: Treatment Administration Record

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second re-visit to the re-licensure survey of 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 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.

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.

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.

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.


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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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 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.

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.

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 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.

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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.

The findings of the re-licensure survey, conducted 5/10/21 through 5/12/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 5/12/21, conducted 10/4/21 through 10/5/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second revisit to the re-licensure survey of 05/12/21, conducted on 12/02/21, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to:Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control.Resident 4 was admitted to the MCC in 4/2021. Observations and interviews with staff during the survey revealed s/he had an indwelling Foley catheter and was incontinent of bowel. S/he relied on staff for incontinence care needs. a. Resident 4 was observed in bed on 5/11/21 at 9:15 am. The urine bag was not attached to the bed and was lying on the floor. There was no barrier between the bag and the floor to prevent cross contamination.b. At 9:30 am the same day, the surveyor obtained permission and observed a CG provide ADL care to Resident 4. During the observation, the CG failed to change gloves after removing a soiled incontinence product, wiping feces from Resident 4's perineum, and handling the catheter bag. The CG touched the resident's clothing, clean incontinence brief, slippers, eyeglasses, wristwatch, bed linens and a staff communication-device while wearing the same soiled gloves. The above observations were discussed with Staff 1 (MCC Administrator) on 5/12/21. She acknowledged appropriate infection control practices were not implemented. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair and the dish machine was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 5/11/21 at 11:00 am, the main kitchen was observed to need cleaning in the following areas:a. The dish washing station had:- A large trash can with dried-on food;- The dish machine, electrical box, walls, floor and pipes under the dish machine and sink had an accumulation of black matter, debris and food matter;- A puddle of water underneath the three compartment sink from a clogged drain; - Upright units that stored clean dishes had black matter and dried food debris on the shelves and trays; and- The dish machine wash cycle was observed three times. It did not reach manufacture required temperature.The surveyor toured the dish washing station with Staff 14 (Dining Services Manager). He ran the dish machine and confirmed the wash cycle was not at the required manufacture temperature. He called maintenance staff to fix the dish machine. b. The following was observed in the main areas of the kitchen:- Entrance door to the kitchen had chipped paint and dirt and debris on it;- Floors and tile moldings in the food prep and cook area had thick black matter build-up and food debris in corners, under equipment and around edges/inside of floor drains; - Walls throughout the kitchen had multiple spills, smears, splatters or black streaks;- The upright refrigerator by the stove had food debris on the front, inside and the bottom shelf; - The heater vents had a layer of dust/dirt;- Grease build-up and food debris was observed on stainless steel tables, fryer, stove, grill and underneath appliances;- Plastic storage container underneath the steam table (storing clean items) had food debris on it;- Pipes behind multiple appliances had grease, dirt and debris on them;- Food matter was observed on shelves in the food prep area. Pipes beneath were covered with a layer of dust, lint or grease; - Dried-on food was visible on the sides and underneath the convection oven;- Trash can sides had an accumulation of dried food matter; and- Dried-on food matter, dust and debris was on the Hobart mixer.In an interview with Staff 14, he indicated he did not have a cleaning schedule for staff.At 11:40 am, the surveyor and Staff 2 (Executive Director) toured the kitchen. Staff 2 acknowledged the above areas needed to be cleaned. On 5/13/21 10:00 am, the surveyor observed the dish machine wash cycle operating at the required manufactured temperature. The kitchen was observed and the unsanitary conditions were in the process of being corrected.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:On 10/4/21 at 10:30 am, the main kitchen was toured with Staff 14 (Dining Services Manager). The kitchen was observed to need cleaning in the following areas:* The dish washing station walls had an accumulation of black matter, debris and food matter;* Walls throughout the kitchen had multiple spills, smears, splatters, or black streaks;* The heater vent near the baking food prep area had a layer of dust/dirt;* Pipes underneath the hand washing sink had dark brown matter;* The upright refrigerator by the stove had food debris on the front, inside and the bottom shelf; * Grease build-up and food debris was observed on the sides of the fryer, convection oven, and shelf below the grill;* Plastic storage container underneath the steam table (storing clean items) had food debris on it; and* Food matter and dirt debris was observed on shelves storing clean plates, bowls and cups (shelves on the server side of the steam table).Surveyor and Staff 14 reviewed the cook and server cleaning schedule which was last completed the week of 8/15/21. Staff 14 indicated he did not have time to audit the cleaning schedule to ensure the kitchen was maintained. On 10/5/21 the main kitchen was toured with Staff 14. The above areas were cleaned however, Staff 14 indicated he had not initiated a new cleaning schedule or discussed the need to maintain the cleaning schedule with kitchen staff. On 10/5/21, the areas needing to be cleaned, the lack of a cleaning schedule and weekly audit to ensure the kitchen was maintained in accordance with Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (ED) and Staff 3 (Director of Health Services). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to:During the re-licensure survey 5/10/21 through 5/12/21, there was a lack of scheduled and unscheduled activities provided for residents living in the memory care community.The activity calendar was provided for the MCC during the survey and included scheduled activities for Monday through Friday. Saturday and Sunday there were no scheduled group activities. They were identified only as "Activity Room" or "Dining Room" with no specific activity type or time included. Scheduled group activities during the week were to take place between 10:00 am and 3:30 pm. Any activities after 4:00 pm were only identified as "Activity Room" and no times were included. Activities listed on the calendar for 5/10/21 through 5/12/21 included trivia, art, movie, 1:1 and exercise. Each day at 10:30 am, 1:30 pm and 2:30 pm the calendar only identified "Activity Room" with no specific activity identified. Multiple observations on 5/10/21 through 5/12/21 included a memory activity, two movies on 5/10/21, one resident putting together a puzzle and another doing a word search. The TV was observed to be on all three days. Art and exercise were on the calendar to be done every day but did not occur on any of the three days. During the survey, residents were observed sleeping, wandering the halls, or sitting in front of the TV in the common living room area of the MCC.On 5/10/21, surveyors observed five residents were seated in the dining room, with two staff providing care on the MCC.Staff 5 (MA/CG) was observed assisting a resident with personal care in their room. Staff 6 (MA/CG), initiated a trivia game for the residents who remained in the dining room.A few minutes after starting the activity, a resident in another room required incontinence care. Staff 6 had to stop the activity to assist the other resident, and left the dining room.The five residents remained at the table for several minutes, and were observed asking each other what to do and if the game was over. Observation showed both staff were occupied assisting residents with personal care, and no one was available to continue engaging the residents in the activity.In interview on 5/10/21 Staff 1 (MCC Administrator) said the Memory Care did not currently have an Activity Director and staff were to provide activities in between job duties. The lack of an activity program was discussed with Staff 1 (MCC Administrator) on 5/12/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required components for 1 of 1 sampled resident (#4) whose new move-in evaluation was reviewed. Findings include, but are not limited to:Resident 4 moved into the MCC in 4/2021. The new move in evaluation failed to address the following elements:* Personality, including how a person copes with change or challenging situations; and* Environmental factors that impact the resident's behavior including noise, lighting and room temperature.The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (MCC Administrator) on 5/12/21. She acknowledged the findings. No further information was provided.

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 regarding the delivery of services, and failed to include a written description of who shall provide the services and when, how, and how often the services shall be provided for 1 of 4 sampled residents (#4) whose service plans were reviewed. Findings include, but are not limited to:Resident 4 was admitted to the MCC in 4/2021 with diagnoses which included dementia. During the entrance conference acuity interview on 5/10/21 at 10:00 am, staff stated Resident 4 needed assistance with ADLs, had a Foley urinary catheter and often needed two staff for transfers. Interviews with direct care staff and observations of Resident 4 during the survey revealed s/he was incontinent of bowel, dependent on staff for ADL care, had a urinary catheter, used a scooter for mobility throughout the facility, used ½ bilateral siderails, and often needed two staff during transfers for safety. Resident 4's service plan, dated 4/14/21, revealed it was not reflective of the resident's needs, lacked clear direction regarding the delivery of services, and failed to include a written description of who shall provide the services and when, how, and how often the services should be provided in the following areas:* Mobility;* Assistive devices;* Siderail use;* Fall risk;* Bathing;* Dressing;* Personal hygiene;* Toileting;* Medication Administration;* Foley Catheter;* Home Health services;* Housekeeping; and * Laundry services. The need to ensure the service plan was reflective of Resident 4's current care needs and provided clear direction to staff was discussed with Staff 1 (MCC Administrator) on 5/11/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services and handwritten updates were dated and initialed for 1 of 4 sampled residents (# 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 6 was admitted to the facility in 12/2019 with diagnosis including dementia. Observations of the resident on 10/04/21, an interview with Staff 21 (CG) on 10/04/21 and review of the service plan dated 07/16/21, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Activity preferences; * Meal location preference and set up instructions; * Food preferences and what food and beverages the family supplies; * Ability to communicate needs and wants; * Placement of disposable incontinent pad; * Behaviors and non-drug interventions; * Fall interventions; * Outside provider information including who does what and when; * Toileting needs; and * Barrier cream application. There were multiple hand-written updates on Resident 6's service plan that were not dated or initialed. The need to ensure service plans were reflective of the resident current needs, provided clear caregiving instruction and handwritten updates were dated and initialed was discussed with Staff 1 (MCC Director), Staff 4 (Director of Health Services) and Staff 18 (RN) on 10/05/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 4 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:Resident 3 and 4's most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans.The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (MCC Administrator) on 5/12/21. She acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to monitor the resident's condition until resolution for 1 of 4 sampled residents (#4) who experienced short-term changes of condition. Findings include, but are not limited to:Resident 4 was admitted on 4/14/21 with diagnoses which included dementia.Resident 4's charting notes, reviewed from 4/14/21 through 4/28/21, indicated the facility initiated short-term change monitoring on 4/14/21 when s/he moved in and on 4/25/21 for "loose stools". However, no monitoring until resolution was documented for either change in condition. Failure to monitor short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (MCC Administrator) on 5/12/21. She acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to determine what actions or interventions were needed and monitored weekly through resolution for 1 of 3 sampled residents (#6) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to: Resident 6 was admitted to the facility in 12/2019 with diagnosis including dementia, atrial fibrillation and congestive heart failure. a. The resident's progress notes dated 08/16/21 through 09/27/21, 07/16/21 service plan, subsequent "Temporary Care Plans," and incident reports were reviewed. Resident 6 had two falls on 09/18/21 and one fall on 09/24/21. There was no documented evidence actions or interventions were determined after each fall and the resident was not monitored weekly through resolution.b. The resident's September 1 through October 4, 2021 MARs were reviewed and noted the resident was to be weighed once weekly. There was no documented evidence the resident's weights were taken weekly. Resident 6's monthly weights were as follows: * 08/10/21: 131 pounds; and* 09/10/21: 138 pounds.Between 08/10/21 and 09/10/21 Resident 6 gained seven pounds or 5.07% of his/her body weight which resulted in a significant weight gain.There was no documented evidence the resident was evaluated or referred to the facility RN for an assessment. A weight was requested on 10/05/21 and was recorded as 126 pounds.There was no documented evidence the facility monitored the effectiveness of weekly weights, determined what actions or interventions were required after the weight gain nor was the resident monitored through resolution. The need to monitor short term changes of condition including implementing interventions and monitoring them for effectiveness was reviewed with Staff 1 (MCC Director), Staff 4 (Director of Health Services) and Staff 18 (RN) on 10/05/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the facility RN assessed a resident's significant change of condition for 1 of 1 sampled resident (# 6) who was reviewed for weight gain. Findings include, but are not limited to:Resident 6 was admitted to the facility in 12/2019 with diagnosis including dementia, atrial fibrillation and congestive heart failure.The resident's September 1 through October 4, 2021 MARs were reviewed. Documentation of Resident 6's weights, showed the resident weighed 131 pounds on 08/10/21 and weighed 138 pounds on 09/10/21. The seven pound weight gain constituted a 5.07% increase, which was a significant weight gain.There was no documented evidence an RN completed an assessment for this significant change of condition to include findings, resident status, and interventions made as a result of the assessment. The above information was discussed with Staff 1 (MCC Director), Staff 4 (Director of Health Services) and Staff 18 (RN) on 10/05/21. No further information was provided.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers for 2 of 2 sampled residents (#s 6 and 7) who received outside services. Findings include, but are not limited to: 1. Resident 6 was identified as receiving hospice services. The resident's clinical records and outside provider notes dated 08/16/21 through 10/04/21 were reviewed. On 09/08/21, the provider requested the facility to elevate the resident's legs relating to edema in his/her feet. On 09/23/21, the provider directed the facility not to apply tape to the resident's skin due to his/her skin being "fragile" and the tape "could cause tearing." There was no documented evidence the recommendations were communicated to staff. 2. Resident 7 was identified as receiving home health services. The resident's clinical records and outside provider notes dated 09/13/21 through 09/23/21, were reviewed. Home health speech therapy and RN made the following recommendations: * 09/13/21 - Reduce the risk of aspiration pneumonia by brushing his/her teeth and tongue at least twice daily; * 09/16/21 - "If dressing becomes saturated or wet, please replace a new dressing;" and * 09/20/21 - Aggressive oral care twice daily. There was no documented evidence the recommendations were communicated to staff. The need to ensure the outside provider recommendations were implemented and communicated to staff was discussed with with Staff 1 (MCC Director), Staff 4 (Director of Health Services) and Staff 18 (RN) on 10/05/21. No further information was provided.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 2 sampled residents (#4) who had documented medication refusals. Findings include, but are not limited to:Resident 4's MARs were reviewed for the time period of 4/16/21 through 5/10/21. Staff documented Resident 4 refused:* Atorvastatin (lowers cholesterol) once;* Citalopram (for depression) twice;* Clotrimazole cream (for fungal infection) twice;* Docusate Sodium (stool softener) twice;* Lasix (diuretic) twice;* Mirtazapine (for depression) once;* Ondansetron (for nausea) 10 times;* Potassium (supplement) twice;* Systane eye drops (for dry eyes) three times;* Vitamin B-12 (supplement) twice; and* Vitamin C (supplement) twice.There was no documented evidence the facility notified Resident 4's physician of the refusals.In an interview on 5/11/21, Staff 5 (MA) reviewed the record and acknowledged there was no documented evidence the facility had notified the physician of the refusals. The above information was discussed with Staff 1 (MCC Administrator) on 5/12/21. No further information was provided.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled residents (# 5) who had documented medication refusals. This is a repeat citation. Findings include, but are not limited to:Resident 5's clinical records and MARs/TARs were reviewed during the survey and revealed the resident had multiple medication and treatment refusals on 9/7/21 and 9/12/21. There was no documented evidence the facility notified the physician when the resident refused consent to their orders. On 10/5/21 the failure to notify physicians of the documented medication and treatments refusals was reviewed with Staff 1 (MCC Director), Staff 18 (RN) and Staff 4 (Director of Health Services). They acknowledged the findings. No further documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure resident MARs included resident specific parameters and instructions for PRN medications, for 1 of 3 sampled residents (#4) whose MARs included multiple PRN medications used to treat the same condition. Findings include, but are not limited to:Resident 4 was admitted to the MCC in 4/2021 with diagnoses which included dementia.Residents 4's MARs were reviewed from 4/17/21 through 5/10/21 and the following was noted:* Lack of resident-specific instructions for multiple PRN bowel medications, including which one to administer first.In an interview on 5/11/21, Staff 5 (MA) reviewed the resident's MAR. She confirmed the multiple PRN bowel medications lacked specific instructions for staff. She stated she was unsure which medication should be given first. No further information was provided. The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (MCC Administrator) on 5/12/21. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with restraining qualities was assessed by an RN, PT or OT prior to use, and instruction was provided to caregivers on precautions and correct use of the device for 1 of 1 sampled resident (#4) who had a half-length siderail on their bed. Findings include, but are not limited to:On 5/10/21 at 11:00 am, Resident 4's bed was observed to have half siderails in the raised position. There was no documented evidence the siderails had been assessed by an RN, PT or OT, or evidence CGs had been instructed on precautions and the correct use of the rails.In an interview on 5/11/21 at 2:45 pm, Staff 1 (MCC Administrator) acknowledged an assessment had not been completed, and staff had not been instructed on siderail precautions and their correct use.

Based on observation, interview and record review, it was determined the facility failed to provide sufficient numbers of caregiving staff to meet the 24 hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care. Findings include, but are not limited to:The facility was an endorsed Memory Care Community home to 13 residents at the time of the relicensure survey. During the acuity interview on 5/10/21 the facility was identified to have residents with high ADL care needs, two staff needed for transfer or during care, and dementia diagnoses. The MCC Staffing Plan posted on the wall indicated Day Shift (6:00 am to 2:00 PM) and Swing Shift (2:00 PM to 10:00 PM) would be staffed by two caregivers and one Medication Aide. According to the UDS (Uniform Disclosure Statement), the facility used Medication Aides and Universal Workers (whose job duties included providing care and services to residents in addition to having other tasks, such as housekeeping, laundry and activities.) The (UDS) updated on 3/30/21 indicated Day and Swing shift both would be staffed by one direct care staff, one Medication Aide, one universal worker, with an additional four hours of assistance provided by the Activity Director and an additional direct care staff.If a facility employs universal workers whose duties include other tasks (i.e., housekeeping, laundry, food service,etc.), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.Review of the MCC schedule from 4/1/21 to 5/13/21, observations, and interviews confirmed only one caregiver and one Medication Aide were scheduled to provide resident care and that no activity staff were present on the MCC. In addition to caregiving and medication duties, the caregivers and Medication Aides were "Universal Workers" responsible for:* All cleaning and housekeeping duties;* Laundry service for all residents;* All meal service including, serving and cleaning;* COVID-19 Infection Control procedures; and* Engaging residents in activities.On 5/10/21, surveyors observed five residents were seated in the dining room, with two staff providing care on the MCC.Staff 5 (MA/CG) was observed assisting a resident with personal care in their room. Staff 6 (MA/CG), initiated a trivia game for the residents who remained in the dining room.A few minutes after starting the activity, a resident in another room required incontinence care. Staff 6 had to stop the activity to assist the other resident, and left the dining room.The five residents remained at the table for several minutes, and were observed asking each other what to do and if the game was over. Observation showed both staff occupied assisting residents with personal care, and no one available to continue engaging the residents in the activity.During the survey, observations were completed on day and swing shifts, the activity calendar and staff schedule were examined, and resident records reviewed. In interviews during the survey with residents, family members, and other witnesses, the following was stated/shared with the survey team:* "They have been understaffed for way too long";* "I was there last night and there were only two staff taking care of all the residents. That's not adequate";* "I've reported the lack of staff to the Ombudsman and nothing has changed";* "Too much turnover in staff";* "Staff constantly work double shifts";* "[Corporation] doesn't care about the care, just the bottom dollar";* "The care staff are fantastic";* "[Corporation] management doesn't listen. It's a huge problem";* "Staff don't have enough time to do all that's expected of them";* "Facility needs full time activity staff";* "The care staff don't have time to get everything done";* "Facility staff are overworked. There is too much expected of them and they can't get it all done";* "There is only one CG and one MA when I come to visit";* "There are usually no activities going on because the CGs and MAs are busy providing care";* "One CG and one MA for each shift is not enough";* "The CGs and MAs have too many duties";* "If staff are on break, only one person is available for all the residents";* "The workers are great, but they are frustrated";* "Another caregiver is needed for both the day and evening shift";* "The Activity Director left. There are no activities going on";* "Activities are on and off. They don't happen very often. They don't have anyone for an Activity Director right now"; * "I pay a lot of money for them to have enough staff to care for my [dad/mom]"; and* "The caregiver and med tech don't have time in their shift to do housekeeping, laundry and activities in addition to all their care and medication duties. My [dad/mom] is not getting the care [s/he] needs because of this".The failure to adjust staffing levels, based on caregiving staff duties that included meal preparation and service, activities, housekeeping, laundry services, and meeting the needs of resident's requiring the assistance of two staff was discussed with Staff 1 (MCC Administrator) and Staff 2 (Executive Director). No further information was provided.Refer to C242.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 10 and 17) had documented demonstration of competency in all required areas, completed First Aid certification, and had been trained in abdominal thrust within 30 days of hire. Findings include, but are not limited to:Review of the facility's training records on 5/11/21 at 2:00 PM and again on 5/12/21 at 9:00 AM, revealed:Staff 17 (MA) hired 1/13/21 and Staff 10 (CG) hired 1/15/21, lacked documented evidence observations and evaluations of competency had been completed for all required components within the first 30 days of hire for topics including: * The role of service plans in providing individualized resident care;* Providing assistance with the activities of daily living;* Changes associated with normal aging;* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;* Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and* Documented evidence of First Aid certification and training in abdominal thrust within 30 days of hire. The need to document demonstrated competency in job duties and complete First Aid certification and abdominal training within 30-days of hire was discussed with Staff 1 (MCC Administrator) and Staff 2 (Executive Director) on 5/12/21. They acknowledged the lack of documented evidence the required training had been provided.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code (OFC) and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:Review of fire drill and fire and life safety records for December 2020 through April 2021 identified the following deficiencies:* Fire drills were not conducted and recorded every other month;* Fire and life safety instruction for staff was not conducted and documented on alternate months; and* The facility was not relocating residents during fire drills so there was no documentation of the escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, the evacuation time period needed and number of occupants evacuated.The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (MCC Administrator) and Staff 16 (Environmental Services Director ). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure a written fire drill record was maintained and included all components in accordance to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:Fire drill records for August and September 2021, were reviewed during survey. The following required components were not documented in fire drill records: *Date and Time of the fire drill;*Location of simulated fire origin;* The escape route used; *Problems encountered and comments relating to residents who resisted or failed to participate in the drills;*Evacuation time period needed;*Staff members on duty and participating; and* Number of occupants evacuated. The need to ensure a written fire drill record was maintained and included all components in accordance to the Oregon Fire Code (OFC) was discussed with Staff 1 (MCC Director) and Staff 22 (Maintenance) on 10/05/21. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C240, C260, C270, C305 and C420.

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 C160, C240, C242, C360, C372 and C420.

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 C420.

Based on interview and record review, it was determined the facility failed to maintain documented evidence that 3 of 3 newly hired staff (#s 10, 13 and 17 ) had been provided with the required pre-service training and required training within 30 days or before independently providing care, and that one of one long term staff (#9) completed annual training as required. Findings include, but are not limited to:Review of the facility's training records on 5/11/21 at 2:00 PM and again on 5/12/21 at 9:00 AM, revealed: a. Staff 17 (MA) hired on 1/31/21, Staff 13 (MA/CG) hired on 4/23/21, and Staff 10 (CG) hired on 1/15/21, lacked documented evidence training and evaluations of competency had been completed for all required components within the first 30 days of hire or before independently providing care and services, for topics including: * Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms;* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; * Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: identify and address pain; provide food and fluid; prevent wandering and elopement; and use a person-centered approach;* Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* How to provide personal care to a resident with dementia, including an orientation to the resident and the resident's service plan; and* The use of supportive devices with restraining qualities in memory care communities. b. Staff 9 (CG), hired on 11/9/2016, did not have documented evidence of completing the 16 hours of required annual training.The need to provide pre-service training and to ensure staff have completed training in the required topics within 30 days and that long term staff completed annual training as required, was reviewed with Staff 1 (MCC Administrator) and Staff 2 (Executive Director) on 5/12/21. They acknowledged the lack of documented evidence the required training had been provided.

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 C252, C260, C262, C270, C305, C310 and C340.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C260, C270, C280, C290 and C305.