The Pines at The Canopy -

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 2 of 4 newly hired staff (#s 10 and 18) whose training records were reviewed. Findings include, but are not limited to: Refer to: Z155.

Business Office Director audited all team members and reassigned courses based on the crosswalks between Relias and Oregon Care Partners. All new hires have been assigned the required courses based on the Oregon Care Partners crosswalk. Business Office Director updated our in-house template (copied from OCP crosswalk) to include all current state required trainings and all new nires will be assigned based on this template. All current team members training records will be thoroughly audited the middle of each month. BOD and Administrator will meet once a month.

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule.

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

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired MCC staff (#s 10, 16, and 18) completed all required pre-service orientation training, 3 of 3 newly hired MCC direct care staff (#s 10, 12, and 18) completed all required additional pre-service dementia training, and 2 of 3 newly hired MCC direct care staff (#s 10 and 18) demonstrated competency in all job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 02/03/26 at 12:00 pm with Staff 6 (Business Office Director) and revealed the following: a. There was no documented evidence Staff 10 (CG), Staff 16 (Dining Assistant), and Staff 18 (MT), hired 12/17/25, 12/30/25, and 08/26/25, respectively, had completed one or more of the following pre-service orientation trainings before beginning any job duties: * Resident rights and the values of CBC care; * Infectious disease prevention; *Approved LGBTQIA2S+ course; * Dementia disease process including progression of the disease, memory loss, and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/ fluids, preventing wandering, use of person-centered approach. b. There was no documented evidence Staff 10, Staff 12 (MT), hired 12/02/25, and Staff 18 completed one or more of the following pre-service dementia training topics for direct care staff prior to providing personal care: * Environmental factors that are important to a resident’s well-being (eg. staff interactions, lighting, room temperature, noise, 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 ongoing assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and * Use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 10 and Staff 18 demonstrated competency in one or more of the following areas within 30 days of hire: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation, and reporting. The need to ensure the required pre-service training was completed by staff prior to providing services to resident and staff demonstrated competency in assigned job duties within 30 days of hire was discussed with Staff 2 (Community Administrator), Staff 3 (Wellness Director/ RN), Staff 5 (Life Enrichment Director), Staff 6, Staff 7 (Memory Care Coordinator), Staff 8 (Maintenance Director), and Staff 21 (RCC) on 02/04/26 at 11:30 am. They acknowledged the findings.

Business Office Director audited all team members and reassigned courses based on the crosswalks between Relias and Oregon Care Partners. All new hires have been assigned the required courses based on the Oregon Care Partners crosswalk. Business Office Director updated our in-house template (copied from OCP crosswalk) to include all current state required trainings and all new nires will be assigned based on this template. All current team members training records will be thoroughly audited the middle of each month. BOD and Administrator will meet once a month.

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

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

Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner and ensure food was prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). Findings include, but are not limited to: On 08/28/25, from 11:11 am to 3:08 pm, interviews with staff and observations of the facility kitchen, food storage areas, food preparation, and food service were conducted. The following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: * The flooring throughout the kitchen, janitors closet, and under, behind, and around the ice machine, ovens, convection oven, deep fryer, hot service line, food preparation areas, and storage racks in the walk-in refrigerator; * Interior and exterior of the deep fryer, ovens, and grill; * Interior of the ice machine; * The storage racks in the walk-in refrigerator; * Interior and exterior of two large food storage containers under a food preparation table; * The vents and the ceiling and/or walls near the vents, located in the janitors’ closet, above the three-compartment sink, inside of the walk-in refrigerator, at the top of the standing refrigerator to the right of the hot service line, and four above the hot service line; * The wall to the right of the walk-in refrigerator and near the swinging entry and exit doors; * The seal located around the dish pit in the ware wash area; * The base of an outside company’s bread storage rack; * The flooring in the memory care kitchenette located under, around, and behind the steam table and refrigerator. b. The following areas were noted in need of repair: * The walls in the entry hallway had gouged, broken, chipped, and scratched material; * The tiles located on the corners of the entry hallway were broken and cracked; * Floor drain to the right of the ice machine was missing approximately four inches of the seal; * The storage racks in the walk-in refrigerator had chipped coating; * The standing bread warmer was reported to be inoperable; * The memory care kitchenette entry door had large areas of worn surface material at the top of the door on both sides; and * The walls in the memory care kitchenette had scratches and chips throughout and had peeling material behind the steam table. c. Staff 2 (Director of Culinary Services) reported the facility served eggs with soft yolks, however there were no pasteurized eggs available. d. The walk-in refrigerator had an external thermometer, and two internal thermometers noted to have temperatures ranging from 44 - 53.6 degrees Fahrenheit throughout the survey. Therefore, thermometers were not at the required temperature of 41 degrees Fahrenheit or below. e. While completing a walk-through of the kitchen with Staff 1 (Executive Director) and Staff 2, thawed raw meat was observed on a food preparation table with liquid around the raw meat, dripping into and on one of the large dry food canisters located under the food preparation table. On 08/28/25 at 2:29 pm, Staff 1 and Staff 2 completed a walk-through of the memory care kitchenette and at 2:33 pm, Staff 1 and Staff 2 completed a walk-through of the kitchen with this surveyor and reviewed the above noted areas. The need to ensure the kitchen was maintained in a sanitary manner and food was prepared and served in accordance with Food Sanitation Rules was reviewed with Staff 1 and Staff 2, on 08/28/25 at 3:08 pm. They acknowledged the findings.

• The Culinary Director (CD), Maintenance Director (MD), and Executive Director (ED) conducted a comprehensive walkthrough of all areas identified during the survey. The team completed a deep cleaning of food preparation areas, equipment, vents, and floors under equipment, as well as recaulked the dishwashing area. • The CD removed and disposed of inoperable equipment. • The CD transitioned to pasteurized eggs, which have been delivered and are now in use. • The CD held a documented in-service training with the culinary team addressing cross-contamination prevention. • The MD repaired chipped walls, baseboards, and tiles in the kitchen. • The MD corrected refrigerator temperature concerns, ensuring the unit maintains temperatures below 42°F. • The MD completed a thorough cleaning and sanitization of the ice machine. 2. The CD implemented cleaning logs for both the main kitchen and the Memory Care kitchenette, outlining daily and weekly cleaning tasks. • The CD reviews these logs with the team daily and conducts a weekly sanitation walkthrough with the Sous Chef. • The CD, Sous Chef, and Memory Care Director (MCD) perform a detailed sanitation walkthrough on the first Monday of each month. 3. Daily and weekly walkthroughs of the kitchen are conducted by the CD and Sous Chef. • The CD, ED, and MD jointly conduct a monthly walkthrough of the kitchen, storage closets, dishwashing area, Memory Care kitchenette, and hallways to identify and correct any damaged or chipped surfaces. 4. The CD and Sous Chef oversee all daily cleaning responsibilities. • A weekly sanitation audit is completed for the kitchen, storage areas, Memory Care kitchenette, and dishwashing area by the CD and Sous Chef. • The CD, MD, Memory Care Director/ED conduct a monthly walkthrough of the physical kitchen including MC kitchenette- including walls, tiles, and baseboards, to ensure all areas are maintained in compliance.

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

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

• The Culinary Director (CD), Maintenance Director (MD), and Executive Director (ED) conducted a comprehensive walkthrough of all areas identified during the survey. The team completed a deep cleaning of food preparation areas, equipment, vents, and floors under equipment, as well as recaulked the dishwashing area. • The CD removed and disposed of inoperable equipment. • The CD transitioned to pasteurized eggs, which have been delivered and are now in use. • The CD held a documented in-service training with the culinary team addressing cross-contamination prevention. • The MD repaired chipped walls, baseboards, and tiles in the kitchen. • The MD corrected refrigerator temperature concerns, ensuring the unit maintains temperatures below 42°F. • The MD completed a thorough cleaning and sanitization of the ice machine. 2. The CD implemented cleaning logs for both the main kitchen and the Memory Care kitchenette, outlining daily and weekly cleaning tasks. • The CD reviews these logs with the team daily and conducts a weekly sanitation walkthrough with the Sous Chef. • The CD, Sous Chef, and Memory Care Director (MCD) perform a detailed sanitation walkthrough on the first Monday of each month. 3. Daily and weekly walkthroughs of the kitchen are conducted by the CD and Sous Chef. • The CD, ED, and MD jointly conduct a monthly walkthrough of the kitchen, storage closets, dishwashing area, Memory Care kitchenette, and hallways to identify and correct any damaged or chipped surfaces. 4. The CD and Sous Chef oversee all daily cleaning responsibilities. • A weekly sanitation audit is completed for the kitchen, storage areas, Memory Care kitchenette, and dishwashing area by the CD and Sous Chef. • The CD, MD, Memory Care Director/ED conduct a monthly walkthrough of the physical kitchen including MC kitchenette- including walls, tiles, and baseboards, to ensure all areas are maintained in compliance

Based on observation, interview, and record review, it was determined the facility failed to ensure the service plan was reflective of resident's needs, was readily available to staff, and provided clear direction regarding the delivery of services for 1 of 1 sampled resident (#3) who had a history of elopement. Findings include, but are not limited to: Resident 3 moved into the facility in 06/2024 with diagnoses including dementia, and was identified during the acuity interview as having recently eloped. The resident's current service plan dated 07/07/24, temporary service plans (TSPs) dated 06/28/24 to 07/29/24, and progress notes dated 06/28/24 to 07/29/24 were reviewed, interviews with staff were conducted, and observations of the resident were made. The following was identified: a. The resident's service plan and TSPs were not reflective and/or did not provide clear direction to staff regarding the resident's elopement behaviors. During an interview at 2:18 pm on 08/01/24, Staff 14 (Resident Care Assistant) stated Resident 3 would often wear a badge and carry papers around to "look official," and would attempt to convince visitors to the MCC that s/he was not a resident. During an interview at 2:05 pm on 08/01/24 Staff 18 (Resident Care Assistant) stated the resident would approach visitors and ask to be let out, telling them s/he forgot his/her key. This information was not in the resident's current service plan or TSPs. b. Review of the record revealed TSPs were typically located in the "Memory Care TSPs" binder, available in the staff break room. Two TSPs both dated 06/28/24 with instructions to staff regarding the resident's elopement that same day were located in the resident's hard chart in the locked medication room. The instructions were not on the resident's current service plan available to staff. During an interview at 2:15 pm on 08/01/24, Staff 12 stated, "We are supposed to redirect [him/her] but I haven't been given specific instructions what to do when [s/he] is looking like [s/he] wants to leave." An updated TSP regarding Resident 3's elopement behaviors with clear directions to staff was requested and received by the survey team at 4:00 pm on 08/01/24. The need to ensure service plans were reflective of resident's needs, made readily available to staff, and provided clear direction regarding the delivery of services was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health and Wellness Director), Staff 15 (LPN), and Staff 16 (Assisted Living Coordinator)on 08/01/24. They acknowledged the findings.

New TSP was placed for Resident 3 with more details on elopement behaviors. It will be added to the service plan at the next quarterly update. Care staff have been retrained to read and sign TSPs. On going training will occur from the Clinical team to ensure care staff are reading and signing the TSPs. The Health and Wellness Director will input all relevant TSPs to the service plan at each update (quarterly and as needed). Memory Care Director will check each service plan update to ensure that the relevant TSPs have been entered. Administrator will be responsible that the items above are completed and documented timely.

2. Resident 2 was admitted to the facility in 06/2024 with unspecified dementia and type 2 diabetes. Review of the current service plan, dated 07/28/24, indicated s/he was dependent on staff for toileting and incontinent care and required two person assist for transfers. During an ADL observation on 07/29/24 at 11:18 am the following was observed: *Two caregiving staff provided two person assist to help Resident 2 sit up in bed and transfer into the wheelchair. Once out of the bed, Staff 7 (Resident Care Assistant) removed the soiled disposable pad from the bed and placed it on the bathroom floor next to the trash can; * Resident 2 was escorted to the bathroom and both staff assisted the resident transfer to the toilet, lowered his/her soiled briefs and pants, and assisted the resident onto the toilet. The soiled brief was placed on the floor on top of the soiled pad; * With the same gloved hands, Staff  19 (Resident Care Assistant) donned a clean brief and pants, picked up the pile of dirty clothes and placed them in the hamper, lifted up a blanket on his/her bed, retrieved slippers, returned to the bathroom and put the slippers on the resident's feet. Staff 19 bagged up the soiled briefs and pad, removed her gloves and donned a new pair of single use gloves with no hand hygiene prior; * Staff 7, wearing the same single use gloves, removed the resident's shirt and assisted the resident into a clean shirt; * Resident 2 was assisted to stand by both staff and Staff 7 provided perineal care that included using wipes. Both staff pulled up the resident's briefs and pants, adjusted his/her shirt and gait belt, and assisted the resident transfer into the wheelchair. With the same soiled gloves, Staff 7 then touched the push handles of the wheelchair to move the resident closer to the sink, ran her fingers through the resident's hair, picked up a comb and combed his/her hair. * After the resident washed his/her hands, Staff 7 removed her gloves, donned new gloves with no hand hygiene prior, pushed the resident out of the bathroom and into the hallway while a third staff arrived to escort Resident 2 to lunch. The need to maintain effective infection prevention and control while providing ADL care was reviewed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health and Wellness Director), Staff 15 (LPN), and Staff 16 (Assisted Living Coordinator) on 08/01/24 at 12:15 pm. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 1 and 2) and multiple unsampled residents dependent on staff for care needs and meal service. Findings include, but are not limited to: 1a. Resident 1 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease. Review of the resident's current service plan dated 07/10/24 indicated s/he was dependent on staff for toileting and incontinence care. At 12:30 pm on 07/29/24, Staff 9 (Resident Care Assistant) was observed providing toileting assistance for Resident 1. Staff 9 escorted the resident to his/her bathroom wearing the same single use gloves from lunch service. Staff 9 assisted Resident 1 with pulling pants and briefs down wearing the single use gloves from lunch service. She then provided pericare and assisted Resident 1 in pulling his/her briefs and pants up without disposing of single use gloves and performing hand hygiene between dirty and clean tasks. 1b. General observations were conducted in the MCC from 07/29/24 to 08/01/24. The following was identified: * Multiple care staff were observed entering and exiting unsampled residents' rooms, donning and doffing single use gloves without performing hand hygiene prior to and before assisting residents with ADLs, touching their devices, and touching other surfaces in the community. * Staff 8 was observed exiting an unsampled resident's room with incontinent trash on 07/31/24 at 10:32 am. He was observed to touch another resident's wheelchair handlebar while holding the incontinent trash. He proceeded to another unsampled resident's room and placed the incontinent trash on the resident's floor. He then assisted the unsampled resident to his/her bathroom to provide toileting assistance without first performing hand hygiene. 1c. Observations of meal service were conducted from 07/29/24 to 07/30/24. Caregiving staff were observed serving food and feeding residents without wearing a protective covering over potentially contaminated clothing. The need to maintain effective infection prevention and control protocols was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health and Wellness Director), Staff 15 (LPN), and Staff 16 (Assisted Living Coordinator) on 08/01/24. They acknowledged the findings.

Aprons have been purchased for clothing protection during meal service. Staff have been educated to utilize these at each meal. All staff will be retrained during monthly all staff meeting by the Health and Wellness Director on when to wash hands/change gloves during perineal care/care in the bathroom. Ongoing training and observation by supervisory team members will occur to insure compliance and appropriate Infection Control measures ongoing. Memory Care Director will observe bathroom cares monthly to ensure compliance. Memory Care Director to ensure there are aprons for meals. Health and Wellness Director will be responsible for scheduling/conducting training. Memory Care Director to supervise monthly audits.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were administered only after documented, nonpharmacological interventions were tried with ineffective results for 1 of 1 sampled resident (#1) who had an order for PRN psychotropic medications. Findings include, but are not limited to: Resident 1 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease. The resident's 07/01/24 to 07/29/24 MAR and progress notes and current physician orders were reviewed. The following was identified: The resident had an order for lorazepam, administer one tablet by mouth every four hours as needed for anxiety. The MAR indicated staff administered the PRN medication on six occasions from 07/01/24 to 07/29/24. There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the medication. The need to ensure documentation that staff administered PRN psychotropic medications only after attempting nonpharmacological interventions with ineffective results was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health and Wellness Director), Staff 15 (LPN), and Staff 16 (Assisted Living Coordinator). They acknowledged the findings.

Before giving a psychotropic medication as PRN, the Med Tech will document that they have tried all listed nonpharmacological interventions. Med Techs will be re-trained during a Med Tech meeting to ensure they are aware of where to document that the nonpharmacological interventions were completed. The Health and Wellness Director will evaluate this quarterly. Licensed Nursing staff, led by Health and Wellness Director will work to ensure compliance.

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident 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 30 beds. a. On 07/29/24 during the entrance conference, survey requested a facility staffing policy or a tool to determine number of caregiving staff needed to provide scheduled and unscheduled residents' care needs. Staff 1 (Memory Care Director) stated the facility used the service plan points generated to determine staffing levels, and provided a key that corresponded with the points assigned for care tasks. The facility acuity-based staffing tool (ABST) was reviewed during the survey. b. During the acuity interview on 07/29/24 with Staff 1 (Memory Care Director) and Staff 3 (Health and Wellness Director), the following care needs were identified: * The facility had a census of 23 residents; * Five residents required two-person assistance for transfers, including three who required the use of a mechanical lift; * Four residents required cueing/redirection during meals and/or one-on-one assistance with feeding; and * Ten 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. c. The facility ABST did not generate the minutes needed for staff to provide care in all 22 ADL areas, and did not capture all 22 ADLs for facility residents. Therefore, the tool could not be used to determine an appropriate staffing plan. d. The staffing plan provided by the facility on 07/30/24 was as follows: * Day shift - Three resident care assistants and one MT; * Evening shift - Three resident care assistants and one MT; and * Night shift - Two resident care assistants and one MT. e. Observations and interviews conducted from 07/29/24 to 08/01/24 revealed the following: *Four residents were provided with one-on-one meal assistance for breakfast, lunch, and dinner; *Resident 1 and multiple unsampled residents needed redirection from staff to stay seated to eat meals; * Multiple non-direct care staff, including Staff 1, Staff 2 (ED), Staff 3, Staff 15 (Licensed Practical Nurse) and Staff 17 (Assistant Sales Director) were observed providing meal assistance, serving food/beverages, and escorting residents to and from meals; * A total of nine direct care and non-direct care staff were observed serving residents and/or providing care during meals; * Resident 1 and an unsampled resident, both identified as at high risk for falls, were observed unsupervised while walking around the unit and/or pushing furniture for up to 25 minutes. They were both observed to leave their walkers behind while walking; and * Resident 3 was observed to elope from the locked unit into the lobby twice. * During an interview on 07/30/24 at 1:00 pm, Staff 1 indicated the facility had identified the need to add seven additional hours per day to the staffing plan. She confirmed there was no current plan in place to fill the hours. * During an interview at 3:28 pm on 08/01/24, Staff 13 (MT) stated when the MCC was short-staffed due to staff calling out for their shift, Staff 16 (Assisted Living Coordinator) was supposed to cover the shift, "but that only happens when we're down to one caregiver." Staff 13 further stated that residents often didn't receive showers or other care when staff called out for their shift. * During an interview at 9:34 am on 07/31/24, Staff 7 (Resident Care Assistant) stated weekend day shifts were short staffed due to not having a server for meals, so direct care staff had to serve in addition to providing escorts, one-on-one meal assistance, and redirection. * During an interview on 07/30/24 Staff 11 (Maintenance Director) reported the facility was not relocating residents during fire drills. He further indicated facility procedure during fire drills was to use staff from the separately licensed assisted living facility as part of the fire drill plan. 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 plan of correction to address the insufficient staffing was requested from Staff 1 and Staff 2 at 1:26 pm on 07/31/24, and was received by the survey team at 3:09 pm on 07/31/24. The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents for all shifts was discussed on 08/01/24 with Staff 1, Staff 2, Staff 3, Staff 15 (LPN) and Staff 16 (Assisted Living Coordinator). They acknowledged the findings

On 7/31/24 during survey, a third caregiver for NOC shift was added to the schedule, as well as an extra carestaff during day shift and a half shift for swing. A server is also being hired to ensure that every meal in Memory Care has a server present. The ODHS ABST will be utilized from now on to ensure appropriate staffing. Review of labor will occur at each service plan update by Administrator, Health and Wellness Director, and Resident Care Coordinator. Review and completion will be ongoing by Administrator or designee.

Based on interview and record review, it was determined the facility failed to ensure implementation of an acuity-based staffing tool (ABST) that included all required ADLs and the amount of staff time needed to provide care. Findings include, but are not limited to: On 07/30/24 at 1:00 pm, the facility's ABST was reviewed and discussed with Staff 1 (Memory Care Director) and Staff 2 (ED). Staff 1 and 2 confirmed they used a proprietary ABST using a point system and the ABST was driven by the service plan for each resident. Review of the facility ABST tool revealed there was no documented evidence all 22 of the required ADLs were individually addressed for each resident, nor was the amount of staff time needed for each of the 22 ADL elements. On 08/01/24 at 12:15 pm, the need to ensure the facility used an ABST which met the regulation was discussed with Staff 1 and Staff 2. They acknowledged the findings.

The community will be utilizing the ODHS ABST tool in place of their previous tool to ensure all 22 ADLs are individually addressed for each resident and the amount of staff time needed for each ADL. The service planning team, specifically the Health and Wellness Director, will update the ODHS ABST at each service plan update (quarterly and as needed for any change of condition and for the resident prior to move in when we enter their service plan for our team. It will also be reassessed at 30 days when we administer the service plan as well with any changes. The ABST will be updated at each service plan update. Administrator or desginee will be responsible for accuracy ongoing.

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). Findings include, but are not limited to: Review of fire drill records for February 2024 through July 2024 identified the following: * The facility lacked documented evidence that fire drills were done every other month after April 2024. No further documented evidence was provided upon request; and * The facility had not documented residents being relocated or evacuated during fire drills, therefore there was no documentation of the problems encountered, evacuation time-period needed, number of occupants evacuated and comments relating to residents who resisted or failed to participate in the drills. The need to ensure the facility conducted fire drills per the OFC was reviewed with Staff 11 (Maintenance Director) on 07/30/24 and with Staff 1 (Memory Care Director) and Staff 2 (ED), Staff 3 (Health and Wellness Director), Staff 15 (LPN) and Staff 16 (Assisted Living Coordinator) on 08/01/24 at 12:15 pm. They acknowledged the findings.

One fire drill per shift will be conducted and documented. Each drill will rotate which shift is is completed on. Additionally, all planned fire drills are to be communicated to the Memory Care Director to ensure compliance. Each fire drill conducted will involve evacuating or relocating residents. Assisted Living staff and Memory Care staff will only be used for their designated sections for fire drills. Monthly review of Life Safety requirements, specifically Fire Drills, to be conducted and documented by Maintenance Director. Fire drills will be conducted effective immediately and every other month following with documentation of any problems that occurred, evacuation time period, number of occupants that were evacuated and any comments relating to any resident that resisted or failed to participate in the drills. Administrator will be responsible for oversight of corrections and compliance ongoing.

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to no locks on residents who had shared bathrooms and were not bedbound. Findings include, but are not limited to: Observations of toileting and incontinence care on 07/29/24 and 07/30/24 revealed Residents 1 and 2 did not have a locking mechanism on their respective shared bathroom doors to ensure privacy. During an interview on 07/30/24 at 1:00 pm, Staff 1 (Memory Care Director) and Staff 2 (ED) confirmed that residents who used the toilet in their shared bathrooms did not have locks that would ensure privacy and dignity. They revealed the majority of the residents had shared bathrooms. The inability to lock the door for residents who had shared bathrooms and used the bathroom for their toileting needs jeopardized residents' rights to privacy and dignity. The observations were reviewed with Staff 1, Staff 2, Staff 3 (Health and Wellness Director),  Staff 15 (LPN) and Staff 16 (Assisted Living Coordinator) on 08/01/24 at 12:15 pm. No additional information was provided.

Maintenance Director to install a locking mechanism on the inside of shared bathroom doors to ensure privacy and dignity of the resident. Memory Care Director will ensure that the locks are still in place and not broken. If broken, the Memory Care Director will contact the Maintenance Director to fix the lock. Memory Care Director completes weekly room audits and will check the locks in each room once weekly. The Maintenance Director and the Memory Care Director will work together to ensure the locks are placed, and functioning on the shared bathroom doors.

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to no locks on bathroom doors for residents who had shared bathrooms and were not bedbound. This is a repeat citation. Findings include, but are not limited to: Observations on 12/02/24 of shared bathrooms revealed there was no locking mechanisms on shared bathroom doors to ensure privacy. During an interview on 12/02/24, Staff 11 (Maintenance Director) and Staff 2 (ED) confirmed that residents who used the toilet in their shared bathrooms did not have locks that would ensure privacy and dignity. The inability to lock the door for residents who had shared bathrooms and used the bathroom for their toileting needs jeopardized residents' rights to privacy and dignity. The observations were reviewed with Staff 2, Staff 3 (Health and Wellness Director), and Staff 20 (Memory Care Director) on 12/03/24. They acknowledged the findings.

Maintenance Director to install a locking mechanism on the inside of shred bathroom doors to ensure privacy and dignity of the resident. Maintenance Director is currently getting several bids for door locks. Memory Care Director will ensure that the locks are still in place and not broken. If broken, the Memory Care Director will contact the Maintenance Director to fix the lock. Memory Care Director completes weekly room audits and will check the locks in each room once weekly. The Maintenance Director and the Memory Care Director will work together to ensure the locks are placed, and functioning on the shared bathrrom doors.

Based on observation and interview, 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 07/30/24 at 1:15 pm, Staff 1 (Memory Care Director) and Staff 2 (ED) confirmed the majority of the residents did not have keys to their rooms. Review of Resident 2's evaluation revealed the resident was independent with the use of a key locking device. In an interview with Resident 2 on 07/30/24 at 2:00 pm, s/he indicated s/he did not think s/he had a key to lock his/her room. The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1, Staff 2, Staff 3 (Health and Wellness Director), Staff 15 (LPN) and Staff 16 (Assisted Living Coordinator) on 08/01/24 at 12:15 pm. No additional information was provided.

The Memory Care Director will document and give each resident a key to their lockable unit. The key will be placed in each residents closet on the wall. Upon move in for new residents, the Memory Care Director will offer a key to access to their lockable unit and document that it was given. Documentation will be kept in the service plan. The service plan is reviewed and updated quarterly and as needed The key documentation will be reviewed during each service plan review and update. The Memory Care Director and the service planning team will work together to ensure the correct documentation is in each service plan.

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 and C 420.

See plans for C 295, C 360, C 361 and C 420.

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

See plans for C 260 and C 330.

Based on interview and record review, it was determined the facility failed to ensure each resident was evaluated for activities addressing all required elements and to develop an individualized activity plan based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose evaluations and services plans were reviewed. The most recent evaluations and current service plans were reviewed for Residents 1 and 2. The following was identified: a. There was no documented evidence an activity evaluation had been completed for Resident 1 that addressed the following:   * Current abilities and skills;   * Physical abilities and limitations; and * Adaptations necessary for the resident to participate. b. There was no activity evaluation completed for Resident 2. c. There was no documented evidence an individualized plan was developed for both sampled residents. The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health and Wellness Director), Staff 15 (LPN), and Staff 16 (Assisted Living Coordinator)on 08/01/24. They acknowledged the findings.

Life Enrichment Director will complete the activities evaluation for the two sampled residents. The Life Enrichment Director will use the activity evaluation to complete the individualized activity plan for each resident. Upon move in, the Life Enrichment Director will complete the resident activity evaluation and the individualized activity plan as well as all of the residents individualized activity evaluations updated and completed for Memory Care by 9/30/24. The Life Enrichment Director will post the information in a binder in the breakroom for all the staff to review.   The Life Enrichment Director will review all the individualized activity plans every six months unless a resident experiences a significant chagne of condition which we will update with the residents abilities. The Memory Care Director or designee will be responsible to see that the corrections are completed.

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 H 1510.

The facility will review and comply with all regulations under OAR 411-054-0105. The facility will continue to conduct audits for each apartment on a weekly basis. The Memory Care Director will conduct weekly audits of the bathroom doors for each shared apartment to ensure we are in compliance. The Memory Care Director, Maintenance Director and the Executive Director will work closely together to ensure we are in compliance.

The findings of the re-licensure survey, conducted 07/29/24 through 08/01/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 08/01/24, conducted 12/02/24 through 12/03/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 08/01/24, conducted on 06/26/25 are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure the kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 09/05/23 at 11:00 am, the following kitchen practices were observed: * The facility was not using pasteurized eggs; * Meal trays on the memory care unit were  transported to individual rooms without being covered; and * One kitchen staff was not wearing a beard restraint. The areas of concern were discussed with Staff 1 (Director of Culinary), Staff 2 (Interim Memory Care Director) and Staff 3 (Executive Director) on 09/05/23. The findings were acknowledged.

1) Pasteurized Eggs: Director of Dining Services to order pasteurized eggs from our approved food purveyor; ; training our dining services team on the importance of using pasteurized eggs vs non pasteurized eggs, and potential health risk of food bourne illness to our residents. Administer inservice for the team which will be signed by person in charge and all employees that attend inservice. 2) Meal Tray Covers- Interim AED to inservice our employees and memory care servers to cover food prior to delivery and talk cross contamination is and food safety. We will ensure plate covers/plastic wrap for all food being delivered to the residents apartments as well as any other food transported in/out of the kitchen. 3)Unrestrained Beard- Director of Dining Services/Person in charge to inservice all dining employees on hair restraints in kitchen working with food prep, cooking, dishes and how it can become physical contaminant. Dining team to sign inservice

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

Refer to C240

The findings of the kitchen inspection, conducted 09/05/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 09/05/23, conducted 10/27/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to: During the Change of Management survey, conducted 06/13/22 through 06/17/22, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations. Refer to deficiencies in report.

1. Administrative management team  including Executive Director, department managers  and Park Avenue Life Stye Management for Clinical and Operations Directors have reviewed, revised and updated all policies and procedures and intitiated trainings for all new and existing staff. Please see each citation for more information 2. A change of administrator is in process to provide effective oversight including ensuring the quality of care and servces. An admininstrator and designee have submitted information for approval by DHS. Both are completing required Criminal Background checks and other state requirements including attendance of OHCA Administrator Training Class form 7.25.2022 to 7.29.2022 prior to completing the licensing exam. 3.  Administrative management including community and management company leadership participate in weekly audit reporting with quality improvements. 4. Administrator and/or designee.

Based on observation, interview and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents related to the evacuation capability of the residents and staff. The lack of an updated emergency plan, adequate direct care staff, lack of fire safety evacuation training for residents and staff, and lack of emergency evacuation equipment placed residents at potential risk of harm. Findings include, but are not limited to: 1. The building consisted of four floors, with the endorsed MCC on the first floor and an ALF on the second, third, and fourth floors under a separate license. The MCC had two emergency exits located on the northwest and northeast sides of the MCC. The exit on the northwest side opened to an outside sidewalk, and the exit on the northeast side opened to a stairwell leading down to the parking garage.   During the Change of Management survey, 06/13/22 through 06/17/22, the survey team identified the following concerns:   * The MCC was home to 27 residents, including six requiring two-person assist for transfers with a Hoyer or Sit-to-Stand Lift and 14 residents with high care needs.   * The 06/2022 MCC staffing schedule showed there was one resident care assistant for the night shift and one MT working between the MCC and the ALF, which was under a separate license. On 06/15/22, Staff 1 (Memory Care Director) and Staff 3 (ED) confirmed the staff scheduled at night and stated there was one MT between the MCC and ALF. * On 06/15/22, Staff 3 and Staff 5 (Maintenance Director) were interviewed regarding the facility emergency evacuation plan and training. When asked if the facility had evacuation equipment, Staff 3 indicated she had been trying to get equipment. One resident care assistant on the night shift for 27 memory care residents, including six requiring a Hoyer lift or sit-stand. Staff 3 and Staff 5 acknowledged the need for proper evacuation equipment and the need to for adequate staffing levels. During the interview, the following concerns were identified: * Facility evacuation plan was not updated; * Lack of staff and resident emergency evacuation training; * The MCC residents and staff would need to have emergency evacuation training; and * Facility lacked emergency evacuation equipment needed for evacuating safely.   The above areas were reviewed and discussed, and the need to ensure the facility was prepared, trained, and had adequate staffing in case of an emergency, including the night shift, was discussed with Staff 1, Staff 3, and Staff 5 on 06/15/22. They acknowledged the findings.   The survey team requested the facility provide a short-term and long-term plan of safety which was received on 06/15/22. 2. Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control. * On 06/13/22 through 06/16/22, during meal observations, staff assisted residents to the dining room. Staff did not wash residents' hands, offer hand sanitizer, or provide hand hygiene prior to serving the meals.   * On 06/14/22, the surveyor observed there was no paper towel dispenser available next to a handwashing sink in the activity kitchenette, and there were no paper towels in the dining room kitchenette.   * On 06/14/22 at 12:03 pm, during the lunch meal, an unsampled resident was observed sitting at a table in the dining room spitting on the floor. The staff did not clean the area. The resident was also shouting, and the staff did not redirect. On 06/15/22 at 9:48 am, the resident was observed sitting in a chair next to another resident, spitting on her/his arm and the floor. No staff was present, nor had the area been cleaned.   The need to ensure the facility exercised reasonable precautions against conditions that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Memory Care Director) on 06/14/22. She acknowledged the findings. 3. Refer to C530.

1. Fire and Emergency Evacuation Plan has been reviewed and updated. Evacuation equipment obained and is used in all staff evacuation trainings. All residents have been evaluated for ability and need for level and type of assistance to participate in drills and evacuations. All newly hired staff have been trainied prior to providing services (date or hire). Existing staff are being trained on fire drills and the newly updated Emergency Plan and Evacuation procedrures. 2. & 3. Weekly reports for employees not in attendance for routine monthly training and drills will be sent to each department manager for follow up with employee.  Reisdent Service Plans will reflect willingness and ability to participate in these events, on move in and review/re-evaluated every 90 days or before, if changes in a resident condition.   4. Department Managers and Administrator. Reasonable Precautions 1. All new hires are completing the 2hr infection control. Any current staff that has not completed the 2 hour infection control will be completing this training. RN will be completing training on 8/25 with All Staff. 2. Infection control training added to new hire orientation.   3. Training will be audited weekly for 12 weeks and audits will be reviewed by Quality Assurance Committee and recommedations made based on audit review. 4. Health and Wellness Director (RN) or designee    Adequate Direct Care Staff: 1. State provided acuity-based staffing tool updated by Memory care direcotr at https://ltcfacilityportal.oregon.gov and calculated the number of staff hours required to meet the scheduled and unscheduled needs of all residents in Memory Care: a. Extra staff employed by Cornell Landing were added to all shifts.   Staff reeducated on the acuity guideline policy for all potential move-ins. The acuity guidelines require the interdisicplinary team to discuss the acuity of a resident prior to move-in and ensure that staffing levels and/or equipment available will meet the needs of the resident. 2.and 3. Staffing hours will be monitored on a monthly basis by the Resident Care Coordinator, the Health & Wellness Director, and the Memory Care Director. When alterations to staffing hours are required based on the above-mentioned procedure, a determination will be made to hire more staff or in the case of a short-term change in condition bring outside providers (i.e., hospice, home health, agency, etc.). 4. The Memory Care Director under the direction of the Executive Director and the Health and Wellness Director will make the determination to approve new move-ins, hire staff, and/or bring in outside providers. Emergency Evacuation Equipment: 1. The following evacuation equipment has been purchased: a. 4 Evac-chairs have been purchased and will be placed in the stair wells on each floor - two on the NE and 2 on the NW stairwells. b. Evacation blankets Have been purchased and will be kept in various locations throughout the building where staff can easily access them in the event of an emergency requiring their use (i.e., commercial laundry room in Memory Care, Storage closet on 4th floor, etc.). c. Maps and directions for exiting installed at every stairwell. 2. Staff will receive monthly training in emergency and fire/life safety. The Maintenance Director will be responsible for ensuring equipment is located in the correct areas and in good working order. 3. Inspections should be performed on equipment quarterly and after any trainings and/or actual evacuations to ensure equipment is not damaged, in need of repair and/or replacement. 4. The Maintenance Director will monitor quarterly. Universal Precautions for Infection Control: Hand Hygiene 1. Staff have been trained to offer hand hygiene to residents before meals, after activities, and after toileting. The staff have been given training in the importance of hand hygiene before meals as a way to decrease risk cross contamination of germs from hands to food and ultimately into the mouth of residents as well as the risks associated with lack of hand hygiene for both residents and staff. Residents are invited to perform hand hygiene throughout the day using various methods including: a. Use of sink and soap b. Hand sanitizer c. Waterless soap that can be wiped with a cloth or paper towel d. Hand wipes Providing residents with multiple types of hand hygiene and increased opportunities to perform hand hygiene will make it easier for them to perform the process and diminish resistance (although residents are still encouraged to make their own decisions). 2. The systems will be updated in the following ways: a. Frequent in-person training on the importance of hand hygiene will occur regularly with staff. b. Simple signs inviting residents to wash their hands will be placed throughout Memory Care will be placed in highly visible areas. c. Increased monitoring of staff during activities like toileting and meals to ensure that residents are offered frequent hand hygiene as part of their daily routine. 3. This will be monitored daily 1. The Memory Care Director, The Health and Wellness Director, the Assistance Health and Wellness Director, the Resident Care Coordinator with additional oversight and support from the Executive Director.   Paper Towels: 1. New dispenser placed by sink. Paper towels immediatetly filled. 2. Paper towel check added to housekeeping checklist to verify that paper towels are replaced when running low.  back up rolls available for staff use.  Staff educated on location.

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs. Findings include, but are not limited to: Observations made on the memory care unit between 06/13/22 and 06/17/22 revealed there were no group activities occurring on a consistent basis. Multiple residents who were in the common areas, throughout the survey, were not provided any individual or group activities. Residents were observed sitting in common areas for long periods of time watching television, people-watching or remained in their rooms. Multiple residents were observed pacing the halls frequently without being engaged in any individual or group activities. Further observations included: * The activity calendar posted on the unit included providing meals and snacks to residents; * On 06/14/22, crafting, soccer practice and interactive games were scheduled on the  calendar but not offered on the unit; * On 06/15/22, balloon volleyball, science labs and happy hour were scheduled on the unit but not offered; and * On 06/16/22, brain busters, "get fit", stories by the fireplace and walks around the neighborhood were scheduled on the calendar but not offered on the unit. Staff were observed, on two occasions, escorting a small group of residents off the memory care unit to attend an activity at the assisted living facility upstairs. During an interview on 06/14/22, Staff 1 (Memory Care Director) stated the facility had hired a new activity director, however the employee had not yet started working. She further stated an activity aide and the direct care staff were providing activities as time allowed between resident care and other duties. Interviews on 06/15/22 with multiple facility staff revealed there were currently no activity staff assigned to the memory care unit to conduct activities on the unit. An activity staff from the assisted living facility upstairs provided games, puzzles, pictures for coloring, etc. for direct care staff to engage in one on one activities as time allowed. There were no exercise or group activities provided and the activities identified in multiple sampled resident service plans were not provided. The need to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs was discussed with Staff 1 on 06/16/22. She acknowledged the findings.

1. Newly hired Activity Director (AD) has completed evaluations for residents identified during survey including ability, interest and need for any accomodations. Ongoing evaluations of all residents in progress: information for resident choices,preferences, abilities and accomodations are incorporated into their SP. 2. AD will develop new Activity Schedules for regular postings. AD will keeps record of  resident attendance and leve of participation in activittes. AD will follow up residents as needed to determine further interests and and accomodations needed. Life Loop system is being used. 3. AD will generate weekly report to Administrator. 4. Activities Director.

Based on interview and record review, it was determined the facility failed to ensure initial evaluations were updated within 30 days of move-in and quarterly evaluations were completed timely and were reflective of the residents' current needs for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose evaluations were reviewed. Findings include, but are not limited to:   1. Resident 1 was admitted to the facility in 05/2022. Review of Resident 1's records showed the facility completed an initial evaluation dated 05/03/22. Progress notes and incident reports from move-in on 05/03/22 through 06/02/22 revealed the resident had two non-injury falls, one fall with injury, and was sent to the emergency room for elevated blood pressure and an episode of unresponsiveness. There was no documented evidence the initial evaluation had been updated with the documented changes within the first 30 days following the resident's move into the facility.   2. Resident 3 was admitted to the facility in 04/2021. Documentation of Resident 3's quarterly evaluation was requested during the survey. A review of Resident 3's records revealed no evidence of a quarterly evaluation. In an interview with Staff 2 (Director of Nursing Services) on 06/16/22, she confirmed the facility had not completed a quarterly evaluation for the resident.   The need to ensure initial evaluations were updated with changes and modified as needed within 30 days of move-in and quarterly evaluations were completed timely was discussed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings 3. Resident 2 was admitted to the facility in 12/2019. The most recent evaluation was dated 02/11/22. The resident had experienced a decline in multiple areas and should have been re-evaluated in May 2022. The facility failed to update the evaluation at least quarterly. 4. Resident 4 was admitted to the facility in 04/2021. The resident's most recent evaluation was dated 01/26/22. The resident had experienced a general, overall decline and should have been re-evaluated in March 2022. The facility failed to update the evaluation at least quarterly. In an interview on 06/16/22, Staff 1 (Memory Care Director) acknowledged the facility was behind in performing quarterly updates for many of the facility's residents. The need to perform evaluations, at least quarterly, with updates to health status, needs and preferences was discussed with Staff 1 and Staff 2 (Director of Nursing Services) on 06/16/22. They acknowledged the findings.

1. All residents identified during survey have been assessed and evaluations completed with updates and current information.   2. A tracking document /calender has been developed for use as  tool to assist nurses and adminisrator to complete evauations for each recurring SP in advance of 90 days. Addional YARDI (electronic documentation) training has been provided for staff to complete documetnation thouroghly and on time. 3. Daily clinical stand up meetings with nurses and administrator will include review of current evaluations scheduled and completed. Initial evaluations will be completed with documentation prior to move in date for SP development and all staff to follow. New move in Evaluation and SP will be reviewd and updated with in 30 days.  The timeliness of completing all evaluations will be reviewed monthly by  the Quality Improvement Committee. 4. Administrator and/or designee

3. Resident 1 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease and a stroke. Review of the resident's initial service plan dated 05/27/22, and observations and interviews conducted between 06/13/22 and 06/16/22, revealed Resident 1's service plan was completed 24 days after the resident moved into the facility and was not reflective and did not provide clear instruction to staff in the following areas: * Recent falls and interventions; * Episode of unresponsiveness and trip to the emergency room; and * Current skin condition. 4. Resident 3 was admitted to the facility in 04/2021 with diagnoses including Alzheimer's and Dementia with behavioral disturbance. Observations of the resident and interviews with staff from 06/13/22 to 06/16/22 and review of the most current service plan, dated 04/18/21, and temporary service plans revealed the service plan had not been updated for over a year. The service plan was not reflective of the resident's current care needs and lacked specific instruction to staff in the following areas: * Overall decline in physical health and increase in ADL care needs; * Hospice services; * Change in sleep pattern; * Increased aggressive behaviors including altercations with other residents and interventions; * Current level of orientation and ability to understand and be understood; * Toileting and assistance needed; * Skin condition and foot care; * Weight loss and interventions; * Diet and food texture modification; * Nutritional supplement and frequency; and * Falls and interventions. In an interview on 06/14/22, Staff 2 (Director of Nursing Services) confirmed that Resident 3's service plan had not been updated and that the facility was working on reviewing and updating residents' service plans. The need to ensure service plans were reflective of the identified needs and preferences of the resident, provided clear direction to staff regarding delivery of services, were created and updated timely and available to direct staff was discussed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were updated quarterly and reflective of residents' current care needs for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2's service plan, dated 02/11/22, was reviewed along with Temporary Service Plans (TSPs) dated between 03/05/22 and 06/12/22 . The service plan had not been updated, at least quarterly, to incorporate the TSP's that were still pertinent to the resident's care. 2. Resident 4's service plan, dated 01/26/22, was reviewed along with TSP's dated between 02/25/22 and 04/26/22. The service plan had not been updated, at least quarterly, to incorporate the TSP's that were still pertinent to the resident's care. The need to ensure the service plans were updated, at least quarterly and included pertinent information addressed in TSP's was discussed with Staff 1 (Memory Care Director) and Staff 2 (Director of Nursing Services) on 06/16/22. They stated a Resident Care Coordinator was recently hired and updating service plans would be a priority.

1. All residents indentified during the survey have been assessed, service plans have been reviewed and updated appropriately.   2. The tracking doucment tool will be utilized as describe in  POC for C252 to assist nurses and administrtors to track due dates and time lines for all residents' SP 3. Daily clinical stand up will include list of SP coming due and the schedule for completing similar to C252 POC. Audits will be completed twice a month to determine. 4. Health and Wellness Director.

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 3 of  4 sampled residents (#s 1, 2 and  3).  Findings include, but are not limited to: Resident 1, 2 and 3's most recent service plans lacked evidence 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 (Memory Care Director) on 06/17/22. No further information was provided.

1. The Health and Wellness Director or desingee to Contact designated family members along with residents to invite and attend scheduled Service Plan meetings. Service Planning Teams consist or Administrator or designee, Nurse and one other staff member (either Med Tech or caregiver familiar with  the resident service needs) and the team will particiapte in each SP. Service Plan meetings and teams will be scheduled for two different days each week. 2. By setting up  two reoccuring weekly meeting with advance notice to all participants will help to ensure team attendance and timley completion of SP. 3. Weekly as stated in 2 above. 4. Administrator and/or designee.

2. Resident 1 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease.   The resident's 05/27/22 service plan, 05/03/22 through 06/05/22 progress notes, incident reports, and temporary service plans (TSPs) identified the resident had experienced falls on the following dates:     * On 05/05/22 resident had a non-injury fall in the dining room. A TSP written the same day lacked documented resident-specific fall interventions;   * On 05/27/22 resident had a non-injury fall in the dining room. A TSP written the same day lacked documented resident-specific fall interventions; and   * 05/30/22 resident had a fall with injury and sustained a laceration to his/her left lower leg, A TSP written the same day noted a sign was added to the resident's walker to help remind him/her to keep hold of the walker with ambulation. There was no documented evidence the identified intervention was monitored for effectiveness.   The need to ensure the facility determined and documented what actions or interventions were needed and monitored their effectiveness was discussed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions developed, and the condition monitored, for 2 of 4 sampled residents (#s 1 and 2 ) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 2019 with diagnoses including depression and Parkinson's disease. a. A review of the resident's weight records from 01/30/22 through 04/28/22 revealed slow, steady weight loss. There was no documented evidence the facility determined or documented actions or interventions needed to address the weight loss. b. Resident 2 experienced unwitnessed falls on 03/25/22 and 05/10/22. Incident reports were reviewed following the falls. The incident reports did not include any information about the interventions that had been in place at the time of the falls and did not address any new interventions identified as a result of the falls, and to be monitored to determine the effectiveness of the interventions. c. Progress notes documented Resident 2 developed a bruise on 05/15/22. The record lacked any evidence the bruise was monitored, at least weekly, through resolution. The need to identify and monitor changes of condition, identify interventions and monitor their effectiveness was reviewed with Staff 1 (Memory Care Director) and Staff 2 (Director of Nursing Services) on 06/16/22 . They acknowledged the findings.

1. Res #1. A care cooordination meeting plan is in process of completion for fall risk reduction and fall prevention interventions. Pharmacy will review medications that may be contributing fall risk. Physical Therapy and Nursing are completing assessments with person centered approach to interventions to include in the SP. Res #2 A care coordinaiton meeting is planned with Hospice to review the goals of care along with pharmacy review of medicaitons that may be contibuting to loss of appetite /weight loss. 2. A change of conditon system now includes training all staff on  regulations for observing, reporting, monitoring and documenting any noticiable changes in a residents routine or overall conditon. Training on the mandatory use of tools is in process and inlcudes:  STOP AND WATCH  for cargivers and SBAR for Med Techs and Nurses. Alert charting and Temporary or other changes on the SP will be directed by nurses and communicated to health services staff. Nurse is on call for any questions or concerns regarding a resident potential change of condition. Documentation will follow in the progress notes inlcuidng reviewing effectviness of  interventons  and  when a short term condtion has been resolved and wll be taken off ALERT.  An ALERT White Board will be located in MEDROOMS with HIPPA protections for daily tracking at a glance and shift change reporting. 3. Nurses will follow up daily on STOP & Watch and review the ALERT Charting daily. Weekly clincal standup meetings will include  review of all residents CoC on ALERT.   4. Nurses and Administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN completed a significant change of condition assessment, which included findings, developed interventions based on the condition of the resident, and updated the service plan for 2 of 2 sampled residents (#s 2 and 3) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2021 with diagnoses including Alzheimer's disease. Over the past three months, the resident had been diagnosed with COVID-19 and had symptoms, had a decline in physical and cognitive functioning and had been admitted to hospice services. Progress notes dated 03/11/22 through 06/13/22, incident reports, service plans, temporary service plans, and weight documentation were reviewed during the survey. The following deficiencies were identified: * Between 03/29/22 and 05/02/22, Resident 3 lost 8.8 pounds or 6.24% body weight; and * Between 03/29/22 and 06/17/22, Resident 3 lost 23.4 pounds or 16.59% body weight. This weight loss represented a significant change of condition for Resident 3 for which an RN assessment was required. There was no documented evidence the facility RN conducted an immediate assessment of the weight loss which included documentation of findings, resident status and interventions made as a result of this assessment. The resident's service plan was not updated and there was no evidence current interventions were evaluated for effectiveness or new interventions were developed and implemented. The need to ensure significant changes of condition were assessed and documented by the facility RN, and changes were made to the resident's service plan based on the findings of the assessment, was reviewed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings. 2. Resident 2 was admitted to the facility in 12/2019 with diagnoses including depression and Parkinson's disease. During the acuity interview on 06/13/22 the resident was identified as having wound treatments. Resident 2 was observed during the survey with bandages to both outer ankles. The clinical record, including the current service plan, dated 02/11/22, progress notes dated 03/06/22 through 06/13/22, and temporary service plans, were reviewed during the survey and revealed the following: a. On 05/03/22, in the progress notes, the facility RN documented a stage two pressure wound to the resident's left outer ankle and a stage three pressure wound to the resident's right outer ankle. The notes included interventions of requesting Home Health services, continuation of a nutritional supplement and ordering a floor mat. This represented a significant change of condition. There was no documented evidence the facility RN conducted an assessment of the resident's condition which included findings and a description of the resident's status as a result of the assessment. b. Resident 2 had experienced multiple mood changes, medication changes and periods of increased sleepiness. Weight records were reviewed and showed the following information: * On 02/12/22, weighed 145 pounds; * On 03/14/22, weighed  138 pounds; * On 04/28/22, weighed 134 pounds; and * On 06/16/22, weighed 129 pounds. Resident 2 experienced a weight loss of 7 pounds from 02/12/22 to 03/14/22. This was a 4.8% weight loss in 1 month, and on 04/28/22 had lost an additional 4 pounds which represented a significant loss. The facility had not obtained a weight on the month of May. On 06/16/22, Resident 2 was weighed, per the surveyors request, and had lost an additional five pounds since 04/28/22 for a total loss of 16 pounds in three months, which represented 11% of his/her body weight. This represented a significant change of condition. There was no documented evidence the facility RN conducted an assessment of the resident's condition which included findings, a description of the resident's status and interventions implemented as a result of the assessment. In an interview on 06/15/22, Staff 2 (Director of Nursing Services) stated the current (new) electronic system was not programmed to notify staff of a significant weight loss in 3 months. Staff 2 had not been aware of the weight loss, however, she acknowledged the weight loss may have been attributed to the recent medication changes and fluctuating sleep pattern the resident experienced. On 06/15/22, the need to conduct an RN assessment following a significant change in condition, which included all the required elements of an assessment, was discussed with Staff 1 (Administrator) and Staff 2 (Director of Nursing Services). They acknowledged the findings.

1. Res#3 passed away on hospice care7/18/22. Res #2 is currently receiving hospice care and her Service Plan has been updated to reflect this singinficant change of condition. 2.Nurses will follow up with in 24 hours of any potential change of condition with a nursing assessment and documentation in progress notes; either a temporary SP for a temporary change of conditon or a new SP  for a significant change of conditon (such as  the addition of hopsice serivces) or loss of previous functional ability. All accidents, injuries, emergency room encounters will be called to the nurse on call if nurse is not on duty at the time of the incident for timely notificaton and follow up directions for care staff.   3. Daily stand up meetings will include changes to service plans based on changes of resident conditions. any accidents injuries and emergency room visits along with resident changes of condtion. 4. Health & Wellenss Director

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight.  Findings include, but are not limited to: During the change of management survey conducted on 06/13/22 through 06/17/22, administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C 303: Systems: Medication and Treatment Orders; * C 305: Systems: Resident Right to Refuse; and * C 310: Systems: Medication Administration. During the exit meeting on 06/17/22, Staff 1 (Memory Care Director), Staff 3 (Executive Director) and Staff 4 (Assistant Health and Wellness) were informed the overall medication and treatment administration system was determined to be inadequate based on the number of deficiencies related to the above medication areas.

1.All residents identified on survey have been assessed, reviewed and addressed by nurses with specific written and verbal instructions  with Med Techs. Medical orders for time sensitve administration and other tasks related to accurate administrations such as Blood pressures, physical postioning, empty stomach or with food are incuded in the MAR.  Policies and procedures have been reviewed and updated to include time frame for other medicaitons without time sensitivity that include time frames for Breakfast, Lunch, Dinner and Bedtime administration. If medical orders donoot prohibit resident preferences , these will be included on the SP along with time sensitive meds. All resident refusal have been faxed to prescribers.Oregon Care Partners traing on Role of the Med Tech and Safe Mediction Use for Older Adults  has been scheduled for Med Techs and Administrator. 2 & 3. Nurses will review all medical orders and ensure accuracy for time sensitive medicaions administered on time along with MT following the complete medical order and notification to prescriber for all refusals with reason why resident is refusing if known. Nurses will complete audits 2 times weekly for orders and administration accuarcy and follow up. Nurses will , track and report medication errors; and direct staff in the overall safety and well being of the resident in each occurance. 4. Nurses will track and audit weekly for 12 weeks and report monthly to Quality Improvement Committee which inlcudes the Administrtor.

Based on interview and record review, it was determined the facility failed to carry out orders as prescribed for 2 of 4 sampled residents (#s 2 and 4) whose orders and MARs were reviewed. Resident 2 was not administered a time sensitive medication timely which put the resident at risk for potential harm. Findings include, but are not limited to: 1. Resident 2's physician's orders and the 06/01/22 to 06/13/22 MAR, were reviewed. The following deficiencies were identified: Resident 2 was admitted in 12/2019 with diagnoses including Parkinson's disease. Following a neurologist visit on 05/16/22, orders were provided to the facility to administer carbidopa-levidopa 25-100 mg tab (for Parkinson's disease) as follows: Week 1: 1.5 tablet TID: at 7:30 am, 11:30 am and  4:30 pm. The MAR showed the carbidopa-levidopa was administered from 06/02/22 through 06/05/22 at 4:30 am, 7:00 am and 11:30 am.   The MAR instructed staff to administer the medication at 4:30 am instead of 4:30 pm on four occasions. Upon review of actual administration times, medication technician's (MT's) administered the carbidopa-levidopa at incorrect times (when compared to the order) on nine out of twelve occasions between 06/02/22 and 06/05/22. In an interview on 06/15/22, Staff 2 (Director of Nursing Services) acknowledged the order times had been transcribed incorrectly and administered at the incorrect times. The time sensitive importance of the medication put the resident at potential risk of harm. Upon further review of additional administration times, Staff 2 acknowledged MT's administered the carbidopa-levidopa late on three additional occasions between 06/06/22 and 06/13/22, and the MAR listed an incorrect administration time of 7:00 am. 2. Resident 4 was admitted in 04/2021 with diagnoses including Alzheimer's disease and osteoarthritis. Resident 4's physician's orders and the 06/01/22 to 06/13/22 MAR, were reviewed. The following deficiencies were identified: On 05/19/22, a physician's order instructed staff to administer Oxycodone (for pain) and to "give at 0600 prior to getting up for the day ..." The instructions were printed on the MAR, however the MAR showed the administration time for the first dose at 8:00 am. In an interview on 06/16/22, Staff 8 (MT) stated the resident was "already up when [she] administers the 8:00 am dose" of the Oxycodone. In an interview on 06/16/22, Staff 1 (Memory Care Director) acknowledged the findings and stated the administration time would be changed to follow the order as prescribed and MT's informed to ensure the resident receives the medication as intended for pain control. The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 and Staff 2 on 06/16/22. They acknowledged the findings.

See POC C 300C 303- Systems: Treatment orders 1. Resident 2: RN immediately verified correct times were in place on MAR with note of time sensitive medication. Resident 4: RN immediately verified correct times were in place on MAR . RN completed 1:1 training with med tech that gave medication late. 2. Med Tech meeting held 6/28/22 including training on approving medication as prescribed and administering time sensitive medications correctly. 2 & 3. Nurses will review all medical orders and ensure accuracy for time sensitive medicaions administered on time along with MT following the complete medical order and notification to prescriber for all refusals with reason why resident is refusing if known. Nurses will complete audits 2 times weekly for orders and administration accuarcy and follow up. Nurses will , track and report medication errors; and direct staff in the overall safety and well being of the resident in each occurance. 4. Nurses will track and audit weekly for 12 weeks and report monthly to Quality Improvement Committee which inlcudes the Administrtor.

Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified when a resident refused to consent to a medication or treatment order for 1 of 1 sampled resident (#3) who had documented refusals of medication. Findings include, but are not limited to:   Resident 3 was admitted to the facility in 04/2021 with diagnoses including Alzheimer's and Dementia with behavioral disturbances.   A review of the resident's current physician orders and 05/01/22 through 06/13/22 MARs identified the resident had refused medications on 20 occasions in May and 24 occasions in June.   There was no documented evidence the physician had been notified of the refusals.   The need to ensure the facility had a system to notify the physician or other practitioner when a resident refused to consent to a medication or treatment order was discussed with Staff 1 (Memory Care Director) on 06/17/22.

See POC C 300 Residents PCP has been notified of refusals. Policies and Procedures have been updated to include reporting every time a resident refuses. Med Techs have been instructed on P&P and will document on the electroinc MAR along with faxing the PCP. 2. Health and Wellness Director or nurse designee will audit documenation of refusals weekly. Med Tech will include refusals and notficaitons in shift to shift reports. 3. Health and Wellness Director will audit and report weekly for 12 weeks.  Audits to be reviewed during monthly QA meeting. 4. Health and Wellness Director and/or nurse designee.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included medication-specific instructions when indicated for 1 of 4 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to:   Resident 1 was admitted to the facility in 05/2022 with diagnoses including a stroke, atrial fibrillation (abnormal heartbeat), hypertension, and hypothyroidism. Resident 1's MARs from 05/03/22 through 06/13/22 and physician orders were reviewed and noted the following: * The resident had physician orders for Levothryoyxine (thyroid), Xarelto (blood thinner) and furosemide (diuretic) that required medication-specific instructions. There were no medication-specific instructions ( significant side effects, time-sensitive dosage, when to call the prescriber or nurse) for any medication listed on the MARs; and   * Resident 1's clinical record identified the resident was allergic to donepezil, penicillin, and pollen. There were no documented evidence Resident 1's medication allergies had been transcribed onto the MARs. The need to ensure MARs were accurate, including medication-specific instructions and resident medication allergies, was discussed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings.

1. Resident #1 MARS and SP has been updated with current allergies. 2. YARDI system has been updated to include and transfers this information to MAR. Med Techs will notify nurse if any MAR does not include specific notations for allergies including NKDA (No Known Drug Allergies) Allergies will be included on SP , MARS and will be reviewed every 90 days. 3. MARs will be reviewed by nurses monthly to include allergies. 4. Health and Wellness Director and/or nurse designee.

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:   The endorsed Memory Care Community was located on the 1st floor of a four-story building.  The second, third, and fourth floors were assisted living under a separate license.   The Memory Care Community was home to 27 residents at the time of the survey. During the entrance conference on 06/13/22, the following was identified: *14 residents were identified with high ADL care needs;   * Six residents required two-person assistance for transfers with a Hoyer or Sit-to-Stand Lift; * Four residents needed assistance with meals; and * Four residents were identified with behavioral issues, including resident altercations.   On 06/15/22, the surveyor requested a copy of the staffing plan and the facility's procedure for determining appropriate staffing levels. The staffing plan for the MCC was the following:   Three caregivers and one med tech per day and swing shifts, one caregiver in the MCC, and one med tech working between the MCC and the ALF for the night shift.   During an interview with Staff 3 (ED) on 06/15/22, it was revealed the facility failed to utilize a written, defined system to determine appropriate numbers of caregivers and general staff based on resident acuity and service needs.   Observations and interviews conducted during the survey on 06/13/22 through 06/17/22 showed the following:   * The MCC staff were not direct caregivers but universal workers. In addition to providing resident care, MCC staff duties included setting up and serving food and beverages, cleaning up after meals, light housekeeping, and doing residents' laundry.   The regulation requires that if universal workers are used, the facility must increase the number of staff to maintain adequate resident care and services. The number of staff was not increased to meet resident needs.   * On 06/14/22 at 10:00 am, two residents in wheelchairs and one in a Geri chair were sitting in front of a blank television screen until 10:20 am, when Staff 1 (Memory Care Director) turned on a show for the residents.   * In an interview with Staff 1 (Memory Care Director) on 06/14/22 at 10:32 am, she verified there was no designated activity worker for the MCC that day, and the one activity assistant working was in the assisted living.   * There was a lack of scheduled and unscheduled activities provided for residents living in the MCC;   * Multiple times throughout the survey, three unsampled residents were observed wandering in and out of other resident rooms;   * Staff were interviewed throughout the survey and expressed an overall concern that there was not enough care staff to provide quality care. The MCC residents depended on staff for care needs, nourishment, safety, mobility, activities, and engagement.       * An interview on 06/14/22 at 11:30 am with Witness 1 stated that s/he visited the MCC daily and was concerned with the lack of staffing. Witness 1 further indicated that s/he was worried if s/he was not there, who would assist the resident to the dining room or activities.   The need to ensure the facility had a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and there was a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident was discussed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings.

1. Staffing with full time employees inlcudes the following: Day shift= 1 Med Tech + 3 caregivers.Swing  shift= 1 Med Tech+3 cargvers Night Shift= 1 Med Tech + 2 caregivers. This represents dedicated staff in MC. 2. Acuity Based Staffing Tool used and updated monthly as needed to track resident care for scheduled and unscheduled needs and staffing will be adjusted as required. 3. Monthly or as needed as residents' condition change and or new residents move in. 4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and fire and life safety instruction was provided to staff as required by the Oregon Fire Code (OFC). Findings include, but are not limited to: Review of fire and life safety records provided by the facility on 06/13/22 revealed a lack of documented evidence the facility conducted fire drills every other month and provided fire and life safety instruction to staff on alternate months. On 06/15/22, Staff 4 (Maintenance Director) and Staff 3 (ED) confirmed the facility was not conducting fire drills on the memory care unit nor had staff been receiving fire life and safety instruction on alternate months. The need to ensure the facility conducted fire drills on the memory care unit and provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 Memory Care Director) and Staff 4 an on 06/15/22. Refer to C 160 (1)

1. Maintenance Manager has revised and updated the Emergency Disaster Plan and Fire drill procedures; conducted trainings and evacations with staff and residents; developed alternating monthly schedules for staff and resident trainings and drills. 2. Detailed documentation regarding each training and drill procedure along with attendance is in prgress. Details include but are not limited to evacuation routes,safety points outside the building, how many people participated; amount of time to evacauate etc.,   3. While fire drills are not announced in advance, both veral (daily stand up meetings) and written reports will be provied to administrator for results of drills and trainings utilizing the information required including all required aspects.Sumary reports will be provided to Quality Improvement Committee. 4. Maintenace Manager.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to: Fire and life safety records reviewed on 06/15/22 revealed there was no documented evidence residents were being instructed on fire and life safety procedures within 24 hours of admission and annually. The need to ensure residents were provided instruction per the Oregon Fire Code was reviewed with Staff 1 (Memory Care Director), Staff 3 (Executive Director) and Staff 4 (Maintenance Director) on 06/17/22. They acknowledged the findings.

See POC C420 Residents ability and type of assistance or equipment needed to evacuate has been evauated and included on their SP. Training for Residents on Fire and Life Safety Procedures. 1. While each resident has advanced dementia, it is not prudent to review the emergency evacuation procedures with them on move-in. However, each resident will be included in routine evacuation and emergency drills. Each resident will also be evaluated on move in for what type of assistance may be needed to evacuate the building. 2. Every other month during fire drill procedures, staff will follow SP to assist each resident as needed. 3. SP will be reviewed every 90 days for assistance needed during fire drill to determine if there any changes. 4. Health and Wellness Director or designee

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to: Observations of the memory care environment on 06/13/22 through 06/16/22 showed the following areas in need of cleaning or repair:   * Walls throughout the dining room and kitchenette had food splatters, spills, smears, and    chipped paint; * Food spills and debris were visible along the baseboards in the dining room, and kitchenette; * Dining room and kitchenette flooring had a sticky residue; * Flooring around the kitchenette floor drain was chipped and uneven with stuck-on food particles around the drain, and garbage was in the drain; * Drawers in the kitchenette had food particles; * Accumulation of dust, dirt and food debris was underneath and behind the steam table and refrigerator; * The oven located in the activity kitchenette had a buildup of burnt food debris and grease; * Multiple resident carpets had large stained areas; * Multiple resident baseboards and walls were nicked and gouged; * Multiple chipped and gouged wall corners in resident rooms and bathrooms exposing the metal underneath; * Room 118 bathroom door was missing; * Sections of carpet had been removed in Room 123, exposing the cement floor; * Bathroom in Room 127 had dried fecal matter on and around the toilet and floor; and * There were two laundry rooms on the memory care unit; both had dirt, dust, and detergent on the floors, in between, behind, and on top of the washer and dryers.   The areas needing cleaning and repair were shown to and discussed with Staff 1 (Memory Care Director ) on 06/14/22 and 06/16/22. She acknowledged the findings.

1. Kitchen cleaning and repairs Rsident rooms #118, #123, #127 2. Weekly community rounding to be completed by department heads as assigned by administrator for 12 weeks.  Weekly rounds will be audited by Administrator and/or designeed, identified issues to be addressed in a timely manner and reviewed monthly during QA meeting. 3. Weekly for 12 weeks and reviewed during monthly QA.  QA committee will determine continued need for audits based on review of audtis. 4. Administrator and/or designee.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant to wash soiled linens and clothing and provided a one-way flow of soiled linens and clothing from the soiled area to the clean area. Findings include, but are not limited to: A tour of MCC's two laundry rooms was conducted on 06/16/22 with Staff 10 (Resident Care Assistant) and revealed the following: The MCC used residential washing machines that did not indicate the rinse temperature. The washers were connected to an Ecolab detergent dispenser that was mounted on the wall above the washers, and there was a manual control panel on the wall between the dispensers that had a button for one scoop and a button for two scoops. During the tour at 3:45 pm, the surveyor observed the Ecolab dispensers were empty in both laundry rooms. In an interview with Staff 10 regarding the empty dispensers and the laundry process, she reported that she was not aware of how the dispensers worked, and to start a load of laundry, she added the clothes in the washer, turned the knob to the wash cycle and pressed the hot water button. When asked if she had to push anything on the control panel, she reported no.   In the large laundry room in the MCC, there was a separate soiled utility room with a flushing sink. Staff 10 reported she had never used that room, nor had she seen anybody use it. She further stated that if clothes were extremely soiled, they were placed in the commercial-sized washer, which had an automatic disinfectant dispenser.   At 4:30 pm, the surveyor and Staff 1 (Memory Care Director) toured the laundry rooms and discussed the above findings. She was unaware the detergent dispensers were empty and could not find any detergent. She further reported that to dispense the detergent into the washers, staff had to press either the one scoop or two-scoop buttons for the detergent to be added. Due to the lack of a chemical disinfectant, Staff 1 was instructed not to use the residential washers until they obtained more detergent. She agreed.   The need to ensure the facility had a process for handling and laundering soiled linen, dispensers had detergent, all staff doing laundry were trained on how to use the Ecolab control panel, and there was a one-way flow of soiled linens and clothing from the soiled area to the clean area of the laundry room and staff were trained on when and how to use the flushing sink was discussed with Staff 1 on 06/16/22. She acknowledged the findings   On 06/17/22, that following morning, Staff 5 (Maintenance Director) informed the survey team that the Ecolab detergent had been added to the dispensers.

1. Laundry policy and procdure had been updated to include how to handle soiled laundry, when to use the flushing sink and how to ensure detergent dispensers are kept filled and are operated properly. Laundry needs will be included on Resident Service Plans and indicate staff using disenfecting procedures during laundry cleaning. 2. All new and existing staff are scheduled to complete two hour infecion control training via Oregon Care Partners. Staff meetings scheduled to review and demonstrate updated P&P on Laundry disenfecting, how to obtain detergent refills and activate the disinfectant. How and when to use flushing sink and treat soiled laundry before placing in the machines.   Instructions  will also be posted in laundry rooms for easy reference and reminders. 3. Weekly observation with report to Admnistrator. 4. Maintenance Director.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C150, C160, C242, C360, C420, C422, C513 and C530.

Refer to C 150, C160, C242, C360, C420, C422, C 513 and C530. Trai

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#s 8 and 9) had documentation of completed orientation and pre-service training prior to performing any job duties and demonstrated knowledge and performance in all required areas within 30 days of hire. It was also determined 2 of 2 sampled direct care staff (#s 7 and 18) failed to complete a minimum of 16 hours of annual in-service training annually on required topics, including 6 hours of annual in-service training on dementia care. Findings include, but are not limited to: Staff training records were reviewed with Staff 6 (Business Office Manager) on 06/16/22. She explained the facility had been unable to access the online training records for employees. A review of the records provided revealed the following: 1. Staff 8 (MT) was hired 01/03/22 and Staff 9 (Resident Care Assistant) was hired 04/06/22. a. The facility was unable to provide records of completion of orientation and pre-service training, including dementia training, for Staff 8 and 9. b. Except for certification of First Aid and Abdominal thrust training, the facility was unable to provide documentation of completion of the required competencies within 30 days of hire for Staff 8 and 9. 2. Staff  7 (Resident Care Assistant) was hired 08/24/20 and Staff 18 (Resident Care Assistant) was hired 09/24/20. Review of annual training, based on their anniversary date of hire, revealed the following: a. Staff  7 and 18 lacked documented evidence of having completed at least 16 hours of annual in-service training on topics related to the provision of care for persons in a community-based care setting with at least 6 hours of annual in-service training on dementia care. Staff training requirements were reviewed with Staff 6 on 06/16/22. She acknowledged the findings and stated a plan for the facility to access and track training documentation going forward.

1. Staff # 8 and #9 have completed all required training including  2 hour infection control and 6 hour Pre Service Dementia. Staff # 7 and #18 have completed 16 hours of annual training on required topics including 2. Audits have been completed on all staff to identify what training was completed and when it has been completed. Results of these audits and training requirements outstanding will be reviewed with each employee with expectated dates of completion. Documentation with competencies will be collected and organized in each employee file. Trackkng documents for each required training topic and date completed will be kept in real time. Pre-service trainng will be completed prior to scheduled work with residents. Review of resident service plans and training for any special needs identified on residnets service plan will be included for direct care staff traininng. A list of required trainigs will be developed and provided each employee with deadline completion dates. Annual hours of inservice trainig  for 16 hours will be developed inb advanced and provided to each employeeand wil be posted in the department in advance. 3. Weekly audits will be conducted on new employees and existing staf trainings for 12 weeks.  Talent Acquistion Director will track and coordinate with  Department Managers. Audits to be reviewed monthly during QA meeting. 4. Administrator and/or designee.

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, C280, C300, C303, C305 and C310.

See POC C252, C260, C270, C280, C300, C305, C310.

Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans for each resident were developed and included in service plans for 2 of 2 sampled residents (#s 1 and 3) residing in the MCC. Findings include, but are not limited to:   1. Review of Resident 1's current service plan, dated 05/27/22, identified the resident had a diagnosis of dysphasia and s/he was not to have bread, pasta, or rice due to difficulty swallowing and ensure s/he had fluids; however, there was no resident specific information related to the resident's food and fluid preferences.   2. Resident 3's record was reviewed during the survey. Between 03/05/22 and 06/10/22, the resident experienced significant wt. loss, required a soft diet, nectar thickened liquids, and a nutritional supplement twice a day.   The service plan available to staff and survey was dated 04/22/21. The service plan lacked staff instructions related to the resident's individual nutritional and hydration needs, nor had the service plan been updated regarding the resident's nutritional status.   During the survey, it was observed that snacks were not consistently offered to residents throughout the day, and residents were not encouraged to consume fluids regularly.   The need to develop individualized service plans addressing residents' nutrition and hydration needs and fluids and snacks were consistently offered to residents' throughout the day was discussed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings.

1. Resident 1 and 3 service plans have been updated with each residents food and fluid preferences. Res #3 weight loss has been re-evaluated with updated intervenitons on the SP . Weekly weights as ordered for residents with signficant weight loss will be obtained and reviewed by nurse for further interventions as indicated.  Monthly weights to be obtained for residents without weekly needs. 2.Routine daily hydration rounds will be ocnducted by care staff. In between each meal, 6-8 ounce fluids of choice will be encouraged. Consumption will be noted and reported to nurse if any swallowing difficulty or lack of intake.Care staff will collect each residents food preference; assist them to complete their menu selections and provide information to include on their SP. 3. Weekly aduits of weights to be completed by Health and Wellness Director for 12 weeks.  Audits to be reviewed monthly during QA.      4. Administrator and/or designee.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation and failed to consistently provide meaningful activities for all residents that promoted or helped sustain physical and emotional well-being, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3 and 4's service plans offered some information about the residents' historical and current interests, however, the facility had not fully evaluated the residents': * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There were no specific activity plans developed from the evaluations that detailed what, when, how and how often staff should offer and assist the resident with individualized activities. Observations and interviews indicated the residents were dependent on staff to initiate activities and scheduled activities did not happen with frequency or consistency on the unit. On 06/16/22 the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plans for each resident was discussed with Staff 1 (Memory Care Director) who acknowledged the findings.

See POC C 242 1.Evauatons have been completed for Residents 1, 2, 3 , 4 for current abilities and skills, emotional and social needs and patterns, physical abilities and limtiations, and adaptions need for each to partiicpate in activities they prefer. Challenging behaviors are identified and root cause analysis is used to identify possible triggers for behaviors. These have been included in the updates service plans for staff to follow. Redirections and engaging residents in mantaining routines is included in updated service plans for challenging behaviors. 2. Staff training on challenging beaviors is in progress inlcuding possble triggers. On going use of  reporting tools including STOP AND WATCH and SBAR to provide accuate and timely information for nurse to follow up with TSP for Behavioral Interventions and or additonal interventions is progressing. 3.Daily shift reports will include bevahioral interventions. Health and Wellness Director will evaluate effectivenss and document weekly or more often as needed. Nurse will report in daily stand up meetings. 4. Adminstrator.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 1 sampled resident (#3) with documented behaviors. Findings include, but are not limited to: Resident 3 was admitted to the facility in 04/2021 with diagnoses including Alzheimer's disease. Review of Resident 3's progress notes, temporary service plans, and incident reports identified that between 03/05/22 and 06/10/22, Resident 3 had documented behaviors including exit seeking, agitation, and aggression towards staff and other residents including three resident-to-resident altercations where Resident 3 was the aggressor. There was no documented evidence the facility evaluated Resident 3's behavioral symptoms. The service plan available to staff and the survey was dated 04/18/21 and lacked information about the resident's current behaviors and failed to provide specific interventions or instructions to guide caregivers in monitoring the resident or responding to the resident's behavior symptoms. On 06/17/22, the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Memory Care Director). She acknowledged the findings.

1. Resident passed away on Hospice care 7/18/22. 2. All care staff have been trained on various challenging behaviors; how to approach residents; and report to RN for further evaluation and development of TSP or new Service Plan depending on change of condtion. All residents new to MC will be evaluated and service planned for increased anxiety, exit seeking and wandering due to MC new environmnent and progressive brain disease process. Nurse consultant providing on going reviews and feedback for development of evaluations and service plans to address emotional needs and behaviors. 3. Every 90 days or more often as needed. 4. Health & Wellness Director

Based on observation and interview, it was determined the facility failed to ensure residents' rooms were individually identified to assist residents in recognizing their room. Findings include, but are not limited to: During environmental observations on 06/13/22 and 06/14/22 it was noted seven occupied rooms in the memory care unit lacked identifying information to assist residents with locating their rooms. Though resident names were posted, the size of the postings and print were small. There were no additional individual identifiers outside the resident rooms to assist residents in recognizing their rooms. The need to ensure resident rooms in the memory care unit were individually identified to assist residents in recognizing their rooms was discussed with Staff 1 (Memory Care Director) on 06/14/22. She acknowledged the findings.

1. All residents have their rooms identified on the hallway wall adjacent to their door. A shodow box with resident identified items are depicted in the shadow box. The font size for their name is being enalrged for easier visualization. 2. On the day of move in- each resident's shadow box and name for room identification will be completed and placed near their door. 3. On every new resident 's date of move in. 4. Activity Director.

The findings of the Change of Management survey, conducted 06/13/22 through 06/17/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the change of ownership survey of 06/17/22, conducted 12/27/22 through 12/28/22, 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 and OARs 411 Division 57 for Memory Care Communities.