Brookside Memory Care

The findings of the re-licensure survey, conducted 12/12/23 through 12/14/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 12/14/23, conducted 08/27/24 through 08/29/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second re-visit to the re-licensure survey of 12/14/23, conducted 10/24/24, 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, interview, and record review, it was determined the facility failed to investigate incidents, document all required areas of an investigation, and report to the local SPD office if abuse or neglect could not be ruled out for 1 of 2 sampled residents (#3) with injury from an unwitnessed fall and an incident of resident-to-resident altercation. Findings include, but are not limited to:Resident 3 moved to the facility in 04/2023 with diagnoses including Alzheimer's disease and trigeminal neuralgia.Observations of the resident, interviews with staff, and review of the resident's 11/05/23 service plan, temporary service plans, charting notes, and incident investigations were completed and revealed the following:On 11/17/23 a charting note stated Resident 3 "grabbed a residents face and proceeded to yell at [him/her] and scratched [his/her] neck."In an interview with Staff 1 (ED) and Staff 4 (Memory Care Coordinator) on 12/13/23 at 12:50 pm, they stated there was no documented evidence the occurrence had been reported to the local SPD office. This surveyor requested Staff 1 (ED) and Staff 4 (Memory Care Coordinator) report the above incidents to the local SPD office. Documentation was provided to the survey team to confirm they had been reported to the local SPD office on 12/13/23 at 5:00 pm. The need to ensure incidents are immediately reported to the local SPD office when needed was discussed with Staff 1 and Staff 4. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans included clear direction for staff for 1 of 4 sampled resident (# 1) whose service plans was reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in 08/2023 with diagnoses including dementia with behavioral disturbance.Observations of Resident 1, interviews with the staff, and review of the resident's service plan, dated 11/26/23, showed the service plan was not reflective of the resident's current care needs and lacked clear direction to staff in the following areas:* Eating assistance;* Mobility, including handhold assist;* Fall prevention; and* Evacuation assistance.The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Community Relations Manager) on 12/14/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the facility RN if needed, actions or interventions were developed and communicated to staff, changes were monitored, and progress was documented at least weekly through resolution for 1 of 3 sampled residents (# 1) whose records were reviewed. Resident 1 experienced ongoing severe weight loss. Findings include, but are not limited to: Resident 1 was admitted to the facility in 08/2023 with diagnoses including dementia with behavioral disturbance.The resident's 11/26/23 service plan, 09/24/23 through 12/01/23 narrative charting notes, temporary service plans, and weight records were reviewed.a. Weight records showed the following:* 08/31/23: 155 pounds;* 10/11/23: 141.7 pounds;* 11/21/23: 132.5 pounds; and* 12/12/23: 121 pounds.Between 08/31/23 and 10/11/23 the resident lost 13.3 pounds, or 8.6% of his/her total body weight. There was no documented evidence the facility referred the significant weight loss to the facility nurse for assessment. A 10/08/23 narrative charting note stated that "PCP was notified about 13.3 lbs weight loss. Awaiting response." On 10/15/23 a temporary service plan was initiated and instructed staff "to offer snacks or extra fluids in between meals. [He/she] now has intake monitoring." Resident continued to be weighed monthly. The resident continued to lose another 9.2 pounds, or a 6.5% loss in his/her total body weight, between 10/11/23 and 11/21/23.Resident 1 was observed during lunch meals on 12/13/23 and 12/14/23. S/he frequently rested his/her head on the table and relied on cues from staff to "take two more bites." On 12/13/23 s/he ate one roll and part of a fish stick, leaving carrots and a cheesy potato casserole untouched. Resident 1 was given cues to take "one more bite" and drink some water. On 12/14/23 Resident 1 ate about 60% of lunch which consisted of pepper steak with gravy, rice, sautéed greens and onions, and a roll.On 10/08/23 Resident 1 was identified to have a significant weight loss, and there was no documented evidence the significant change of condition was referred to the facility RN. Resident 1 continued to experience severe weight loss, with no monitoring or progress documented at least weekly.b. The following change of condition lacked documentation of actions or interventions needed for the resident, communication of interventions to staff on all shifts, monitoring, and progress noted at least weekly until resolution:* On 11/01/23 progress notes stated Resident 1 had "increased agitation with care staff, verbally aggressive with other residents ... comes out for breakfast and lunch confused and disheveled, refusing meals, incontinence all over [his/her] clothes, BM [bowel movement] in between [his/her] toes ... and had multiple instances of public urination and incontinence all over [his/her] room, BM and urine on floors, walls, bed, clothes, dresser ..."In an interview on 12/14/23, Staff 11 (CG) stated Resident's 1 behavior with regard to public urination and BM on public walls and flooring did not improve until the implementation of the incontinence one-piece on 11/21/23.c. On 11/05/23 Resident 1 had a fall and told staff s/he tripped over a shoe and fell, resulting in two skin tears. There was no documented evidence of monitoring of the resident after the fall or communicating to staff on all shifts.The need to evaluate changes of condition, refer changes to the facility nurse when needed, determine actions or interventions and communicate them to staff, and monitor through resolution, with at least weekly documentation, was discussed with Staff 1 (ED) and Staff 2 (Community Relations Manager) on 12/14/23. They acknowledged the findings. No further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment included documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (#1) who experienced a significant change of condition. Resident 1 experienced a significant weight loss. Findings include, but are not limited to:Resident 1 was admitted to the facility in 08/2023 with diagnoses including dementia with behavioral disturbance.The resident's service plan, dated 11/26/23, progress notes, dated 09/24/23 through 12/01/23, temporary service plans, and RN assessments were reviewed.During the acuity interview on 12/12/23 Resident 1 was identified to need cuing during meals and as having had weight loss.a. Weight records showed Resident 1 experienced a severe and ongoing weight loss between 08/31/23 and 12/12/23:* 08/31/23: 155 pounds;* 09/11/23: 152 pounds;* 10/11/23: 141.7 pounds;* 11/21/23: 132.5 pounds; and* 12/12/23: 121 pounds.Between 08/31/23 and 10/11/23 the resident experienced a severe weight loss of 13.3 pounds, or 8.6% of his/her total body weight, in six weeks. This change in weight constituted a severe loss and indicated a significant change of condition, which required an RN assessment.On 10/15/23 a temporary service plan was initiated by Staff 4 (Memory Care Coordinator) instructing staff "to offer snacks or extra fluids in between meals. [S/he] now has intake monitoring." The resident continued to be weighed monthly.From 10/11/23 through 11/21/23 the resident experienced a further 9.2 pound weight loss, or 6.5% of his/her total body weight, in six weeks. An RN assessment for the weight change was completed on 11/21/23 and lacked documented evidence of interventions made as a result of the RN assessment.On 12/12/23 the resident's weight was reported to be 121 pounds. This was an additional 11.5 pound loss, or 8.68% of his/her total body weight, in the three weeks since the 11/21/23 weight of 132.5 pounds. Resident 1 was observed during lunch meals on 12/13/23 and 12/14/23. S/he frequently rested his/her head on the table and relied on cues from staff to "take two more bites." On 12/13/23 Resident 1 ate one roll and about 2/3 of a fish stick, leaving carrots and a cheesy potato casserole untouched. Resident was given cues to take "one more bite" and drink some water. On 12/14/23 Resident 1 ate about 60% of this lunch that consisted of pepper steak with gravy, rice, sautéed greens and onions, and a roll. From 08/31/23 through 12/12/23, the resident lost a total of 34 pounds, or 22% of his/her total body weight. An RN assessment was not completed in a timely manner and there was no documented evidence new actions or interventions were identified following the assessment. Resident 1 continued to have severe weight loss.The need to ensure significant changes of condition were assessed by an RN and included findings, resident status, and interventions made as a result of the assessment, as well as ensuring they were completed in a timely manner, was discussed with Staff 3 (Health and Services Director, RN) on 12/13/23 and with Staff 1 (ED) and Staff 2 (Community Relations Manager) on 12/14/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to coordinate on-site health services with outside service providers to ensure that staff were informed of new interventions and the service plan was adjusted if necessary for 1 of 2 residents (#2) who received outside services. Findings include, but are not limited to:Resident 2 was admitted to the facility in 05/2020 with diagnoses including diabetes, and was identified during the acuity interview as receiving outside provider services due to recent hip surgery.Resident 2's 09/13/23 through 12/08/23 charting notes and outside provider notes were reviewed and showed the following:* 11/21/23: "Hip precautions - no crossing legs, no turning toes in, no hip flexion" less than 90 degrees, no bending down to toes.There was no documented evidence the specific hip precaution recommendations were communicated to staff or the service plan was updated to ensure continuity of care.The need to ensure on-going coordination of care with outside service providers was discussed with Staff 1 (ED) and Staff 3 (Health and Services Director, RN) on 12/13/23 and 12/14/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control for protocols to provide a safe, sanitary, and comfortable environment for 1 of 1 (#1) sampled residents and have a designated "Infection Control Specialist." Findings include, but are not limited to:1. In an interview on 12/12/23, Staff 1 (ED) reported the facility did not have a designated individual to be the facility's "Infection Control Specialist," responsible for carrying out the infection prevention and control protocols, qualified by education, training, and experience or certification, and who had completed specialized training in infection prevention and control protocols.The need to ensure the facility had a qualified "Infection Control Specialist" was discussed with Staff 1 and Staff 4 (Memory Care Coordinator) on 12/14/23. They acknowledged the findings.
2. Resident 1 was admitted to the facility in 08/2023 with diagnoses including dementia with behavioral disturbance.Observations of the resident revealed s/he needed physical assistance from one staff for incontinence care, including cueing, wiping, and clothing adjustment.On 12/13/23, at 11:00 am, the surveyor observed one caregiver providing incontinence care for Resident 1. The caregiver failed to change gloves after removing a soiled incontinence brief and the resident's soiled clothing. The caregiver proceeded to touch the resident's clean incontinence brief, lower legs, incontinence one-piece clothing, and shoes. The caregiver doffed both gloves and performed hand hygiene prior to disposal of the resident's garbage.Following care, the surveyor reviewed the observations with regard to maintaining effective infection prevention and control while providing incontinence care. The caregiver verbalized understanding.The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED) and Staff 2 (Community Relations Manager) on 12/14/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (# 1) whose medication orders were reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in 08/2023 with diagnoses including dementia with behavioral disturbance.The resident's 11/01/23 through 12/12/23 MARs and physician orders signed 11/22/23 were reviewed.Resident 1 was admitted to hospice services on 11/22/23, and his/her physician prescribed mirtazapine 7.5 mg daily. This order was not transcribed to the MAR.In an interview on 12/13/23 with Staff 1 (ED), he indicated, "We don't have that medication." An interview on 12/14/23 with Staff 4 (Memory Care Coordinator) confirmed the mirtazapine had not arrived from the pharmacy as of 12/14/23.The need to ensure physician orders are carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (Community Relations Manager) on 12/14/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included reason for use and resident-specific parameters for PRN medications for 2 of 3 sampled residents (#s 1 and 2) whose medications were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 05/2020 with diagnoses including asthma.Resident 2's 12/01/23 through 12/12/23 MAR was reviewed during the survey and found to be lacking resident-specific parameters and instructions for the following medications:* Staff signed on the MAR that they administered insulin when Resident 2 administered the insulin;* Multiple PRN anti-diarrhea medications lacked clear parameters related to when and in what sequence they should be administered; and* Two inhalers, Flovent and Advair, were scheduled in the morning and indicated "Do not administer Flovent with Advair." There were no further instructions clarifying the time frame between administration of the two inhalers.On 12/13/23 and 12/14/23, the need for resident-specific parameters and clear instruction for unlicensed staff was discussed with Staff 1(ED) and Staff 3 (Health and Services Director, RN). The findings were acknowledged.
2. Resident 1 was admitted to the facility in 08/2023. The resident's 11/01/23 through 12/14/23 MARs and physician orders were reviewed and revealed the following issues:a. Resident 1's MAR listed chlorthalidone 25 mg daily for fluid retention. The physician's order, dated 11/22/23, stated the medication was for depression. There was no documented evidence the facility clarified the indications for use.b. Resident 1's 12/2023 MAR listed mirtazapine, but did not include an accurate reason for use.The need to ensure MARs were accurate and included reasons for use for all medications was discussed with Staff 1 (ED) and Staff 2 (Community Relations Manager) on 12/14/23 at 1:15 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:a. On 12/13/23 at 11:30 am, the ABST was reviewed with Staff 1 (ED) and identified the generated staffing level was not being followed. b. Observations were conducted of Resident 3 throughout the survey and the resident's current service plan and evaluation, both completed 11/05/23, progress notes dated 09/13/23 through 12/12/23, and ABST report was reviewed and revealed the following:The ABST report for Resident 3 was not reflective of the resident's current care needs and had an inaccurate amount of minutes assigned in the following areas: * Monitoring behavioral conditions;* Bowel and bladder management; and* Supervising, cueing or supporting while eating.c. Observations were conducted of Resident 1 throughout the survey and the resident's current service plan and evaluation, both completed 11/26/23, progress notes dated 09/24/23 through 12/01/23, and ABST report was reviewed and revealed the following:The ABST report for Resident 1 was not reflective of the resident's current care needs and had an inaccurate amount of minutes assigned in the following areas:* Monitoring behavioral conditions;* Ensuring non-drug interventions for behavior;* Bowel and bladder management; and* Supervising, cueing or supporting while eating.The need to ensure the ABST tool addressed the amount of staff time needed to provide care to the resident and the facility staffed to the ABST generated staffing level was discussed with Staff 1 (ED), Staff 2 (Community Relations Manager), and Staff 4 (Memory Care Coordinator) on 12/14/23. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure the facility was staffed to meet or exceed the ABST generated staffing plan. This is a repeat citation. Findings include, but are not limited to:Throughout the 08/27/24 to 08/29/24 survey, observations were made, the ABST and August 2024 staffing schedule were reviewed. Review of the ABST generated staffing plan found the required staff needed for the 08/28/24 day shift was thirteen direct care staff. Observations on 08/28/24 and review of the facility's 08/2024 staff schedule found the facility staffed seven direct care staff for day shift on 08/28/24.The need to ensure the facility was staffed to meet or exceed the ABST generated staffing plan was discussed with Staff 1 (ED), and Staff 4 (Owner) on 08/29/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month per the Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:On 12/13/23, fire drill and fire and life safety training records for staff, dated 03/22/23 thru 12/12/23, were reviewed. The following deficiencies were found:a. The facility lacked documented evidence unannounced fire drills were conducted every other month and included the following components:* Location of simulated fire origin;* Escape route used;* Problems encountered, comments relating to residents who resisted or failed to participate in the fire drills;* Number of occupants evacuated; and* Evidence of alternate routes used.b. There was no documented evidence fire and life safety instruction was provided to staff on alternating months.On 12/13/23 at 11:03 am, the requirement to ensure unannounced fire drills were conducted and documented every other month, including all required components, and fire and life safety instruction was provided to staff on alternate months was discussed with Staff 1 (ED) and Staff 2 (Community Relations Manager). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents received instruction in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building within 24 hours of admission, and were re-instructed at least annually. Findings include, but are not limited to:In a 11:03 am interview on 12/13/23, Staff 1 (ED) confirmed the facility did not provide instruction in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places to residents within 24-hours of admission or re-instruction at least annually. Staff 1 stated the residents were not able to remember, therefore the instruction was not required. The survey team informed Staff 1 the requirement did not apply for residents whose mental capability did not allow for following such instruction only.The need to ensure residents were instructed in fire and life safety within 24 hours of admission and re-instructed at least annually was discussed with Staff 1 on 12/14/23. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:Refer to C 361.

Based on observation and interview, it was determined the facility failed to ensure the indoor environment was kept clean and in good repair. Findings include, but are not limited to:During observations conducted 12/12/23 thru 12/14/23, the following were found to be in need of cleaning:* Walls in soiled laundry room located by units 19 and 30 had spills/splatters; * The exterior of the flushing rim sink located in the soiled laundry room by units 19 and 30 had brown/black splatter;* Wire shelving in the laundry room by unit 19 had a build-up of brown/orange build-up; and* Table bases in dining room had dirt, food debris, and spills/splatters.During observations conducted 12/12/23 thru 12/14/23, the following were observed to need repair:* Two light bulbs needed replacement, located in the hallway by room 19;* The leather armchair seat cushions, located in the main living room and the piano room, had torn and stained material;* The sink located in the shower room near unit 20 was not sealed to the wall;* The wall corner at the entry of the shower room near unit 20 had gouged, chipped, and missing material, exposing metal; and* The entry door frames of units 21, 22, and 23 had gouges and scratches exposing bare wood and/or there were partially completed repairs to the doors which did not have a smooth surface.During observations conducted 12/12/23 thru 12/14/23, the interior of the facility was observed to have a persistent and pervasive odor in and around the shower room located near unit 20.On 12/12/23 at 2:36 pm findings of the environment, including two light bulbs that were out by room 19, was reviewed with Staff 1 (ED), Staff 4 (MCC), and Staff 2 (Community Relations Manager). They acknowledged the findings. On 12/13/23 at 9:45 am, Staff 1 (ED) stated that the light bulbs had been replaced. Areas in need of cleaning or repair were shown to Staff 16 (Owner) on 12/14/23.The need to ensure the facility was clean and in good repair was discussed with Staff 1 on 12/14/23. He acknowledged the findings.

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 231, C 295, C 361, C 420, C 422, and C 513.
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 361.

Based on interview and record review, it was determined the facility failed to ensure completion of annual infectious disease training for 1 of 2 veteran non-direct care staff (#15). Findings include, but are not limited to:On 12/14/23 training records were reviewed with Staff 1 (ED). The following deficiencies were identified:There was no documented evidence Staff 15 (Cook), hired on 09/07/21, had completed annual infectious disease prevention training. The "Infection Control Training" provided on 03/11/23 failed to identify the content of the training.The need to ensure all staff completed infectious disease training annually, was reviewed with Staff 1 (ED) on 12/14/23. He acknowledged the findings.

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

The findings of the kitchen inspection, conducted on 01/12/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit to the kitchen inspection survey of 01/12/23, conducted 4/11/23, 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 and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:a. On 01/12/23 at 10:30 am - 11:20 am, the facility kitchen was observed and the following areas were in need of cleaning and repair:* Wall behind of coffee pot area had spills and drips;* Floor around a deep fryer and stove had grease buildup;* Drain under the two-compartment sink had brown matter buildup;* Oven knobs had grease buildup;* In the corner near the stove, grill and ice machine the floor had brown matter buildup;* Edge of steamer/heater had food debris and grease buildup; and* Bottom vent of the ice machine had a layer of dust.b. Multiple opened boxes of coke were stored on the direct contact surface.c. A large stainless-steel bowl of salad and a jar of juice were not covered in the refrigerator.d. On 01/12/23 at 11:05 am, Staff 5 (Cook) was observed and the following was noted:* Staff 5 prepared garlic butter bread with plastic gloved hands;* During the preparation of the bread, Staff 5 walked away from the tray line and went to the dry food storage area and refrigerator then touched an oven knob and the refrigerator handle with the same gloved hands;* Staff 5 went back to the tray line without changing gloves or washing his hands;* Staff 5 was observed grabbing shredded cheese with the same gloved hands; and* The surveyor directed Staff 5 to change gloves during the bread preparation.The above findings were shared and discussed with Staff 1 (Co-owner), Staff 2 (Co-owner) and Staff 3 (Community Relations Director) on 01/12/23 during the exit interview. They acknowledged the findings.

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 limited to:Refer to C 240.