Kinsington Oak Grove

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

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: On 11/17/25, from 1:33 pm thru 2:00 pm, the facility main kitchen was observed, and the following was identified: 1. The following areas needed cleaning: * Baseboards throughout the kitchen, especially in the corners, had a build-up of black residue; * Dry food storage area had a ceiling vent with layers of dust. The bottom vent of the ice machine had layers of dust. Drain near the ice maker contained brown residue or food build-up; * Walk-in cooler contained an open bag of shredded cheese that was not dated. The vent and sprinkler heads had layers of dust; * Walk-in freezer had a broken bottom shelf, and the floor had scattered food and debris; * A portable fan had layers of dust and was operating during the kitchen tour, blowing directly toward the clean equipment storage rack; * Drain under the three-compartment sink had black residue; and * Wall and interior of the janitor’s sink had brown residue. 2. The following areas needed repair: * Dry food storage area had ceiling lights with no covers on three of the fixtures; * Walk-in freezer had a broken bottom shelf; and * Colored cutting boards were heavily scored - uncleanable surfaces. 3. Observations of the Maple Cottage kitchenette on 11/18/25 at 11:19 am revealed the following: * Wall near the trashcan had visible food residue and spills; * Exterior of the cabinet and drawers, particularly at the edges, were worn, exposing raw materials and sticky to the touch; * Inside of the cabinets and drawers had visible spills, debris, dust, and water damage; * Inside of cabinets had multiple bags of opened bread, a box of cereal, and a package of cookies that were not dated; * One freestanding refrigerator did not have a thermometer inside or outside and had multiple opened bags of bread, eggroll wrappers, milk, and dressing that were not dated; * A container of sugar on the countertop was uncovered; * Wall under the soap dispenser at the handwashing sink had missing paint or gouges, revealing raw materials; and * One cabinet door next to the dishwasher was loose. 4. Observations of the Pine Cottage kitchenette on 11/18/25 at 11:30 am revealed the following: * A trashcan was not covered when not in use; * Exterior of the cabinets and drawers, particularly at the edges, were worn, exposing raw materials and sticky to the touch; * Inside of the cabinets and drawers had visible spills, debris, dust, and water damage; and * Inside of cabinets had multiple bags of opened bread, a box of cereal, and a package of cookies that were not dated. 5. Observations of the Oak Cottage kitchenette on 11/18/25 at 11:38 am revealed the following: * Wall near the trashcan and eye station had visible food residue and spills; * Exterior of the cabinets and drawers, particularly at the edges, were worn, exposing raw materials and sticky to the touch; * Inside of the cabinets and drawers had visible spills, debris, dust and water damage; * Inside of cabinets had bags of opened bread that were not dated; * Cabinet under the three-compartment food warmer had spills and cracks; * One cabinet door was missing; * Kitchen door frame had food debris and spills; and * The supporting panel under the countertop had food debris, chips, and gouges. The areas of concern were observed and discussed with Staff 1 (Administrator), Staff 2 (Dietary Supervisor), Staff 4 (Director of Nursing), Staff 5 (LPN), Staff 6 (Admission Coordinator), and Staff 7 (RCM) on 11/18/25 at 12:15 pm and at 12:26 pm. The findings were acknowledged.

C240 1: The identified areas on the SOD have been cleaned throughly. The areas also were added to the weekly deep cleaning list. With follow being conducted by head of kitchen, Head of housekeeping, and Administrator. 2: The areas identified that were in need of repair. The identified areas that needed to be repaired have been addressed. Lights fixed, New cutting boards ordered, and broken bottome shelf parts ordered to repair. Maintance is to fix and report once fixed to the Administator to follow up on repairs. 3. Maple Cottage kitchenette: Area's that required cleaning have been cleaned. Added to weekly spot checks. House keeping to maintain area in each cottage. All foods have been dated and will be spot checked by kitchen staff. Thermometer's added to each fridge.

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

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

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

see C 240

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

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-to-resident physical altercations were immediately reported to the local SPD office, and /or injuries of unknown cause were reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse for 3 of 3 sampled residents (#s 4, 5 and 6) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the memory care facility in 04/2023 with diagnoses including dementia with behavioral disturbances. The resident's service plan dated 05/29/24, incident investigation reports, progress notes from 03/01/24 through 06/03/24, observations of the resident, and interviews with care staff during the survey indicated the resident ambulated independently throughout the facility and had been involved in several resident-to-resident altercations. The resident's clinical record revealed the following: * 03/15/24: "Another resident notified caregivers that resident's [Resident 4] hand was bleeding ... Resident has 2 skin tears on hand ... Resident is unable to explain how skin tear was caused ..." Although the facility completed an incident investigation report, there was no evidence the injury of unknown cause had been reported to the local SPD office as required. In an interview with Staff 8 (LPN) on 06/05/24 at 4:25 pm, she reviewed the resident's record and stated the incident had not been reported to the local SPD. She was asked to report the incident. Findings were reviewed with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. The findings were acknowledged. Case intake numbers were provided prior to survey exit. 2. Resident 5 moved into the memory care community in 03/2020 with diagnoses including vascular dementia. Review of the resident's 03/01/24 through 06/03/24 progress notes showed the following: * 03/21/24 "Resident has a light yellow discoloration on left knee."; * 03/28/24 "Resident had discoloration on [his/her] left forearm and hand."; * 05/02/24 "Resident has 2 small discoloration spots on right knee"; and * 05/10/24 "discoloration on left arm." In a 06/05/24 interview with Staff 1 (Administrator), she reported when staff identified skin issues, the skin issues would be reported to the facility nurse who would follow up on the skin injuries. She confirmed there was no incident report or other document confirming the facility conducted an immediate investigation into the injuries to conclude the injuries were not the result of abuse or neglect to Resident 5. On 06/05/24 at 12:38 pm, Staff 1 confirmed the physical injury had not been investigated nor reported to the local unit. The surveyor requested Staff 1 report the incident to the local SPD office. Confirmation that the report had been sent to the local APD office was provided prior to survey exit. The need to ensure investigations into physical injuries of unknown cause were documented to include the injuries were not the result of abuse or neglect was discussed with Staff 1 on 06/05/24 and Staff 8 (LPN) on 06/06/24. They acknowledged the findings. 3. Resident 6 moved into the memory care community in 03/2024 with diagnoses including Alzheimer's disease. Review of the resident's 03/21/24 through 06/01/24 progress notes showed the following: * 04/16/24 - Bruising "right lower butcheek and right arm"; * 04/30/24 - " a baseball sized bruise with like a road rash or rug burn on the inside."; * 05/12/24 - " Open area on right side of buttocks"; and * 05/26/24 - "bruising/discoloration to arm and bottom" In a 06/05/24 interview with Staff 1 (Administrator), she reported when staff identified skin issues, the skin issues would be reported to the facility nurse who would follow up on the skin injuries. She stated that she was going to check documentation of the the physical injury. On 06/05/24 at 4:00 pm, Staff 1 confirmed there was no documented evidence the facility conducted an immediate investigation to reasonably conclude the above physical injuries were not the result of abuse and it was not reported to the local SPD office. The surveyor requested Staff 1 report the incident to the local SPD office. Confirmation that the report had been sent to local APD office was provided prior to survey exit. The need to ensure investigations into physical injuries of unknown cause were documented to include the injuries were not the result of abuse or neglect was discussed with Staff 1 on 06/05/24 and Staff 8 (LPN) on 06/06/24. They acknowledged the findings.

1. C231:The injuries of unknown origin were reported to APs, and intake numbers were obtained. 2. C231: On 6/11/24, employees attended a staff in-service on abuse reporting and injury of unknown origin reporting. 3. C231: The resident care manager will monitor skin sheets and follow up on any areas of concern daily and weekly. 4. C231: The LPN will be responsible for following up and processing any changes of condition.

2. Resident 13 moved into the memory care community in 08/2024 with diagnoses including dementia. Review of the resident's 01/22/25 through 04/23/25 progress notes showed the following: * 02/15/25: Open area on the left leg. In an interview with Staff 8 (LPN) on 04/24/25 at 1:50 pm, she reported there was no incident report or other documentation confirming the facility conducted an immediate investigation into the injuries to conclude the injury was not the result of abuse or potential abuse to Resident 13. The surveyor requested Staff 8 report the incident to the local SPD office. Confirmation that the report had been sent to the local SPD office was provided prior to survey exit. The need to ensure investigations into physical injuries of unknown cause were documented to include the injuries were not the result of abuse or potential abuse was discussed with Staff 8 and Staff 29 (ED) on 04/24/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to immediately investigate incidents of abuse, suspected abuse, or an injury of unknown cause to rule out possible abuse or report to the local SPD office if abuse could not be ruled out, and take measures necessary to protect residents and prevent the reoccurrence of abuse, for 3 of 3 sampled residents (#s 11, 13, and 14) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 11 moved into the memory care community in 04/2023 with diagnoses including dementia. The resident's facility records including progress notes, dated from 01/20/24 through 04/23/25, the 09/23/24 service plan that was available to staff, Temporary Service Plans, dated from 01/02/25 through 04/03/25, and Incident Reports were reviewed. There was no documented evidence the following incidents were reported to the local SPD office or that the facility had immediately investigated the incidents in order to rule out abuse or suspected abuse, and/or take measures necessary to protect residents and prevent the reoccurrence of abuse: * 12/20/24: Staff documented in a progress note, "Resident has dark purple bruising to left hand" with no other documentation of how or when Resident 11 sustained the bruising; * 01/03/25: Staff documented in a progress note, "bruising to right hand is not longer visible" with no other documentation of how or when the resident sustained the bruising; and * 01/17/25: Staff documented in a progress note, "resident has new discoloration to left hand, resident unable to state where it came from." A copy of the confirmations that the facility reported the above incidents to the local SPD office was provided on 04/24/25. The need to ensure the facility immediately investigated incidents of abuse, suspected abuse, or an injury of unknown cause to rule out possible abuse or report to the local SPD office if abuse could not be ruled out was reviewed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 5:14 pm. They acknowledged the findings. 3. Resident 14 moved into the memory care community in 02/2025 with diagnosis including dementia with anxiety, Alzheimer's disease, and vertigo. The resident's record, including the most recent service plan, dated 02/05/25 with handwritten updates on 03/11/25, progress notes, dated 02/05/25 through 04/24/25, and Temporary Service Plans were reviewed. The following was identified: There was no documented evidence the following incidents were reported to the local SPD office or that the facility had immediately investigated the issue in order to rule out abuse or possible abuse: * 02/10/25: The resident "will pour water on other residents"; * 02/10/25: Resident 14 "was hitting staff and other residents"; * 02/14/25: "Discoloration on top of right foot"; * 02/14/25: Skin tear on back of hand; * 03/07/25: Bruise to right arm "yellow in color"; and * 03/17/25: "red marks on shoulder". On 04/24/25 at 4:00 pm, survey requested facility staff report the above incidents to local SPD and confirmation of the reports was received at 6:27 pm. The need to ensure the facility immediately investigated incidents of abuse, suspected abuse, or an injury of unknown cause to rule out possible abuse or report to the local SPD office if abuse could not be ruled out was reviewed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 6:36 pm. They acknowledged the findings.

1: Corrective actions were completed prior to state survey leaving the facility. All APS reports sent with investigations attached. Confirmation of fax to APS received prior to exit of state survey. 2: The System has been updated with education provided on incident reporting by the shower aid. Shower sheets plus incident reporting of unknown injuries education completed. 3: Five days a week during clinical review. 4: Clinical staff participating in clinical review. I.E.Administrator, RN, LPN, RCC, RCM. or subset of

Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large. Findings include, but are not limited to: The facility was divided into three memory care units: Pine, Oak, and Maple. At the time of the survey the facility was home to 52 residents: 16, 18, and 17, respectively. During the interview on 06/05/24 at 1:40 pm, Staff 6 (Activities Director) stated she hosted or facilitated resident activities during her scheduled hours Monday through Friday. Weekend activities were scheduled to be facilitated by caregivers. During the interview with Staff 17 (CG) and Staff 24 (CG) on 06/05/24 at 2:10 pm both confirmed facility staff conducted the activities during weekends but only in the afternoon and depending on staff's availability. The June 2024 Activity Program calendar provided to the survey team indicated the following activities would occur during the survey: 06/03/24: * Caregiver planned activities 06/04/24: * 10:00 am - Seated stretch program * 2:00 pm - Balloon Toss 06/05/24: * 10:00 am - Breathing and Yoga program * 2:00 pm - Painting seashells 06/06/24: * 10:00 am - Seated Cardio program a. Observations in the Oak and Pine Units, from 06/03/24 through 06/05/24, revealed most of the activities listed on the calendar were either not held or substituted with a different activity in each unit. A television played continuously in both units, and residents were observed in their rooms, wandering the halls, or sitting asleep in common areas for long periods of time. b. Random observations in the Maple Unit from 06/04/24 thorough 06/05/24 revealed the following facility led activities occurred: - 06/04/24 at 11:10 am: Seated stretch program; and - 06/05/24 at approximately 3:30 pm: Painting. No other facility led activities occurred in the Maple unit. The need to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large was reviewed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings. No further information was provided.

1. C242: The facility will designate a staff member to be responsible for activities daily until a full-time activity person can be hired and trained. 2. C242: The Resident Care Manager will monitor cottages daily to ensure the planned daily activities are completed. When the Resident Care Manager is off, the Resident Care Coordinator will conduct the walking rounds to ensure activities are being completed. 3. C242: Individual activity assessments will be completed for each resident by July 30th, 2024. 4. C242: The Resident Care Manager will ensure the activity assessments are completed.

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, and created opportunities for active participation in the community at large. This is a repeat citation. Findings include, but are not limited to: The facility was divided into three memory care units: Pine, Oak, and Maple. At the time of the survey the facility was home to 53 residents: 19, 17 and 17, respectively. At the time of the survey, the Activity Coordinator was off work. on personal leave. In an interview on 09/10/25, Staff 2 (Chief Operating Officer) acknowledged the Activity Coordinator had been off work and direct care staff were expected to be providing activities for the residents. The activity calendar that was posted in each unit was for the month of August. Staff 17 (CG) confirmed no activity calendar had been developed for September and the Activity Coordinator had been off work for the past "two or three weeks." The August calendar indicated one activity was scheduled in each unit in the morning and after lunch. The activities were scheduled to last between 30 minutes and one hour, except where a movie was scheduled. Staff explained that the Activity Assistant had led the activities until she went on leave. Observations by the survey team while they were on survey in the building between approximately 2:30 pm - 5:00 pm on 09/08/25, 8:30 am - 5:00 pm on 09/09/25 and 8:30 am - 12:00 pm 09/10/25 noted the activities provided to residents were: * 2 to 3 residents on the Maple and Oak units were offered coloring sheets; * 2 residents on the Pine unit sat at the dining table and read through some picture books and magazines; * A CG painted one resident's finger nails on the Pine unit on 09/08/25; and * A CG on the Oak unit was trying to engage 3 - 4 residents in kicking a large ball between them on 09/09/25. In each unit during the survey, there were some residents who were in their rooms, 5 -6 residents sitting in the living room area on couches while the TV played a movie or TV show, and several residents roaming the hallways. A few residents sat on the couches or at a dining table or in front of the fireplace and occasionally conversed with each other. Occasionally, when staff had time, a CG would sit on a couch and talk with some residents. In an interview on 09/10/25, Staff 24 (CG) stated CGs found it difficult to provide activities for residents because they lacked supplies and guidance. Staff 24 said the only activity she felt CGs offered were coloring sheets and acknowledged residents often got bored of the same activity. The facility lacked a daily program of social and recreational activities that addressed resident interests and met their physical, mental, and psychosocial needs. The need to develop and implement an activity program was discussed with Staff 29 (Administrator), Staff 3 (Director of Nursing) and Staff 2 (Chief Operating Officer) on 09/09/25 and 09/10/25. They acknowledged the facility had not been providing activities.

1. The facility has appointed a full-time Activities Director to oversee the planning and implementation of resident engagement programs. Resident specific preferences are captured and put into the residents care plan 2. An Activities Assistant will be designated to ensure continuity of services in the event of unforeseen circumstances or staff absences, or designee. Thereby maintaining uninterrupted departmental operations. 3. The Activities Department will be subject to weekly evaluations conducted through scheduled walkthroughs to verify adherence to the posted activity calendar. Additionally, a monthly planning meeting will be held to review and finalize the calendar for the upcoming month. 4. These measures are being implemented under the supervision and authority of the Facility Administrator.

3. Resident 4 was admitted to the memory care facility in 04/2023 with diagnoses including dementia with behavioral disturbances. During the acuity interview on 06/03/24 and an interview with Staff 8 (LPN) on 06/05/24 at 2:50 pm, staff stated quarterly and significant change evaluations and service plans were combined into one document. Observations of the resident, staff interviews, and review of the record during the survey revealed s/he needed staff assistance with ADL care needs and did not advocate for him/herself or request assistance. Between 03/01/24 and 06/03/24, the resident had experienced falls, hospitalizations, several resident-to-resident altercations, medication changes, skin injuries, and home health services. Resident 4's most recent evaluation, dated 05/29/24, was not reflective of the resident's health status or current needs, in the following areas: * Customary routines: bathing; * Visits to the health practitioner(s), ER, hospital in the past year; * Personality: including how the person copes with change or challenging situations; * Eating and dental status; * Ability to use call system; * Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Indicators of nursing needs; * Fall risk or history; * History of dehydration or unexplained weight loss or gain; * Recent losses; and * Environmental factors that impact the resident's behavior including but not limited to: noise, lighting, and room temperature. The need to ensure Resident 4's evaluation was reflective of his/her health status and current needs was discussed with Staff 8 (LPN) on 06/05/24 at 2:50 pm, and with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings. No other information was shared. 4. Resident 3 was admitted to the memory care facility in 09/2023 with diagnoses including dementia, depression, and diabetes. During an interview with Staff 8 (LPN) on 06/05/24 at 2:50 pm, she stated Resident 3's quarterly evaluation and service plan were combined into one document. Observations and interview with the resident, staff interviews, and review of the record during the survey were conducted. Resident 3's most recent evaluation, dated 04/08/24, was not reflective of the resident's health status or current needs in the following areas: * Customary routines: sleeping, eating and bathing; * Visits to the health practitioner(s), ER, hospital in the past year; * Mental health issues including: presence of depression, thought disorders or behavioral or mood problems; * Personality: including how the person copes with change or challenging situations; * Ability to use call system; * Pain: non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Nutritional habits and fluid preferences; * History of dehydration or unexplained weight loss or gain; * Recent losses; and * Environmental factors that impact the resident's behavior including but not limited to: noise, lighting, and room temperature. The need to ensure Resident 3's evaluation was reflective of his/her health status and current needs was discussed with Staff 8 (LPN) on 06/05/24 at 2:50 pm, and with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings. No other information was shared.

Based on observation, interview, and record review, it was determined the facility failed to ensure initial evaluations addressed all the required elements, for 1 of 1 newly admitted resident (# 6) and quarterly evaluations were the foundation used to develop residents' quarterly service plans, including documentation relevant to the residents' needs and current condition for 3 of 5 sampled residents (#s 3, 4 and 5) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 6 moved into the memory care community in 03/2024 with diagnoses including Alzheimer's disease. The resident's initial evaluation was reviewed and it failed to address the following required elements: * Interests, hobbies, social, leisure activities; * Spiritual, cultural preferences and traditions; * Physical health status including vital signs if indicated by diagnosis, health problems or medications; * Personality including how the person copes with change or challenging situations; * List of treatments; * Smoking, ability to smoke safely; * Alcohol and drug use; and * Environmental factors that impact the resident's behaviors including, but not limited to noise, lighting, room temperature. The need to ensure the initial evaluation included all required elements was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer) and Staff 8 (LPN) during interviews on 06/05/24 and 06/06/24. Staff acknowledged the findings. 2. Resident 5 moved into the memory care facility in 03/2020 with diagnoses including vascular dementia. During an interview with Staff 2 (Chief Operating Officer) on 06/03/24, he reported the resident's quarterly evaluation and service plan were combined into one document. Observations of the resident, staff interviews, and review of the record during the survey were conducted. Between 03/01/24 and 06/03/24, the resident had experienced falls, hospitalizations, and skin injuries. Resident 5's most recent evaluation, dated 04/02/24, was not reflective of the resident's health status and current needs in the following areas: * Customary routines: sleeping, eating and bathing; * Personality: including how the person copes with change or challenging situations; * Ability to use call system; * Hydration and nutrition status; and * Environmental factors that impact the resident's behavior including but not limited to: noise, lighting, and room temperature. The need to ensure Resident 5's evaluation was reflective of his/her health status and current needs was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24 at 5:28 pm. They acknowledged the findings.

1. C252: The facility has ensured the proper evaluation form is currently in use. 2. C252: Service plans will be updated with all of the identified information by 8/5/24. 3. C252: Staff have attended an in-service training to address the completion of service plans. 4. C252: The Resident Care Manager will update service plans weekly as needed. The service plan team will meet to review updates to the service plans.

3. Resident 3 was admitted to the facility in 09/2023 with diagnoses including dementia and diabetes. Observations and interview with the resident, interviews with staff, review of the resident's 04/08/24 evaluation and service plan, 03/01/24 through 06/03/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident's service plan, dated 04/28/24, was not reflective and/or lacked resident-specific direction for staff including who, what, when, how and how often to provide service in the following areas: * Who to report new complaints of pain; * Frequency of safety checks; * Activities and life enrichment; * Bathing; * Housekeeping; * Medication management; * Laundry assistance; * Making bed; and * Personal shopping assistance. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff including who, what, when, how and how often to provide service was discussed with Staff 8 (LPN) on 06/05/24 at 2:50 pm, and with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings. No further information was provided. 4. Resident 4 was admitted to the memory care facility in 04/2023 with diagnoses including dementia with behavioral disturbances. Observations of the resident, interviews with staff, review of the resident's 05/29/24 evaluation and service plan, 03/01/24 through 06/03/24 temporary service plans, progress notes, physician communications, home health visit notes, and incident investigations were completed. The resident's service plan was not reflective and/or lacked resident-specific direction for staff including who, what, when, how and how often to provide service in the following areas: * Toileting assistance; * Transportation; * Activities and life enrichment; * Bathing; * Housekeeping: "Daily tidy by care staff"; * Medication management; * Dressing/undressing; * Diet; * Use of glasses; and * Grooming. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff including who, what, when, how and how often to provide service was discussed with Staff 8 (LPN) on 06/05/24 at 2:50 pm, and with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings. No further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs, and included a written description of who shall provide the services and when, how, and how often the services shall be provided, for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the memory care community in 03/2020 with diagnoses including vascular dementia. The resident's 04/02/24 service plan, 05/24/24 through 05/29/24 temporary service plans, were reviewed, observations were made, and interviews with caregivers were conducted between 06/03/24 and 06/05/24. Resident 5's service plan was not reflective, and did not provide clear direction to staff including what, when and how often services shall be provided in the following areas: * Use of fall mattress; * Activities and life enrichment; * A relationship with another resident; * Assistance needed for toileting and dressing; * Health shakes status; * Oral health status; and * Use of glasses. The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff including what, when and how often services shall be provided was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. The findings were acknowledged. 2. Resident 6 moved into the memory care community in 03/2024 with diagnoses including Alzheimer's disease. The resident's 05/09/24 service plan and 04/29/24 through 05/24/24 temporary service plans, were reviewed, observations were made, and interviews with caregivers were conducted between 06/03/24 and 06/05/24. Resident 6's service plan was not reflective, and did not provide clear direction to staff including what, when and how often services shall be provided in the following areas: * A relationship with another resident; * Activities and life enrichment; * Cognition, including memory, orientation, confusion and decision making abilities; * Use of a walker for ambulation; and * Use of a splint on ring finger. The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff including what, when and how often services shall be provided was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. The findings were acknowledged. 5. Resident 1 was admitted to the memory care facility in 02/2023 with diagnoses including dementia without behavioral disturbances. Observations of the resident, interviews with staff, review of the resident's 05/01/24 service plan, 05/17/24 temporary service plan, progress notes, and home health visit notes were completed. The resident's service plan was not reflective and/or lacked resident-specific direction for staff including who, what, when, how and how often to provide service in the following areas: * Activities and life enrichment; * Eating including safe feeding instructions and protein shake status; and * Hospice comfort care interventions. The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff including who, what, when, how and how often services shall be provided was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. The findings were acknowledged. 6. Resident 2 was admitted to the memory care facility in 02/2023 with diagnoses including cerbrovascular accident (stroke) and dementia without behaviors. Observations of the resident, interviews with staff, review of the resident's 05/01/24 service plan, 03/13/24 through 05/15/24 temporary service plans, progress notes, physician communications and home health visit notes were completed. The resident's service plan was not reflective and/or lacked resident-specific direction for staff including who, what, when, how and how often to provide service in the following areas: * Activities and life enrichment; * Eating including signs/symptoms of aspiration and safe swallow instructions; * Transfers including step by step instructions for two person transfer; and * Hospice comfort care interventions. The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff including who, what, when, how and how often services shall be provided was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. The findings were acknowledged.

1. C260: All resident service plans will be updated by the service plan team. 2. C260: The service plan team will receive training by the regional nurse and administrator to ensure all aspects of the service plan are person-centered for each resident. 3. C260: The facility administrator will meet with the service plan team weekly until completed. 4. C260: Facility Administrator.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and provided clear direction to staff regarding the delivery of services, for 2 of 3 sampled residents (#s 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the memory care community in 05/2024 with diagnoses including Alzheimer's disease and anxiety. The resident's current service plan dated 09/25/24 was reviewed, observations were made, and interviews with caregivers were conducted between 11/12/24 and 11/14/24. Resident 8's service plan was not reflective and did not provide clear direction to staff in the following areas: * Level of assistance for eating; * Meal assistance needs, including pacing strategies; * Preference of eating with hands; * Level of assistance for bathing; * Level of assistance for dressing/undressing; * Level of assistance with brief changes; * Behavior of taking other residents' food; and * Use of chew toy. The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer), Staff 3 (RN), and Staff 8 (LPN) on 11/14/24. They acknowledged the findings. 2. Resident 7 moved into the memory care community in 09/2022 with diagnoses including Alzheimer's disease.    Observations of the resident, interviews with staff, and the 11/01/24 service plan and Temporary Service Plans (TSPs) from 08/16/24 through 10/30/24 were reviewed during the survey and identified Resident 7's service plan was not reflective of his/her status and did not provide clear direction regarding the delivery of services in the following areas: * Use of PPE (Personal Protective Equipment) for bowel incontinence care; * Use of an air mattress; * Two staff to assist with bathroom use and dressing; * Cognition status including ability to choose clothing and menu items; * Morning care assistance; * Shower assistance; and * Use of wheelchair with a pressure sensor.   On 11/14/24 at 11:09 am, the service plan was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer) and Staff 3 (Facility RN). Staff acknowledged the service plan was not reflective of the resident's status and lacked clear direction to staff.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans that were available to staff were updated quarterly, reflective of residents' current care needs and preferences, provided clear direction regarding the delivery of services, or were implemented for 4 of 4 sampled residents (#s 11, 12, 13 and 14) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 13 moved into the facility in 08/2024 with diagnoses including dementia without behavioral disturbance and anxiety. Observations were made of the resident and interviews were conducted with facility staff. The service plan, dated 03/27/25, and Temporary Service Plans, dated 12/16/24 through 03/28/25, were reviewed during the survey and revealed Resident 13's service plan was not reflective of his/her status and did not provide clear direction regarding the delivery of services the following areas: * Use of a floor mattress; * Use of a wheelchair; * The method of taking medication: crushed medication versus whole; * Use of partial dentures and instructions for cleaning and storing them; and * Transfer status. The need to ensure service plans were reflective of resident needs and preferences and provided clear direction to staff was discussed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 1:50 pm. The findings were acknowledged. 3. Resident 11 moved into the memory care community in 04/2023 with diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety. The service plan available to staff, dated 09/23/24, and Temporary Service Plans, dated 01/02/25 through 04/03/25, were reviewed. Observations were made of the resident and staff were interviewed. The service plan was not reflective of the resident's status, did not provide clear direction regarding the delivery of services, nor was implemented in the following areas: * Behaviors and what triggers the behaviors; * Behavior interventions; * Caregiving staff to apply powder after assisting the resident to the restroom; * Ability to verbalize pain; * The use of a bed and chair alarm; * Chronic skin condition; * Transfers best when s/he has something to hold on to (e.g. grab bar); * Preferred beverages; * Staff are to assist with brushing his/her teeth after every meal; and * Staff assistance needed for daily telephone calls to spouse. On 04/24/25 at 1:13 pm, Staff 8 (LPN) reported that she had updated Resident 11's service plan since 09/23/24 and stated, "We've had a problem with staff not filing [the service plans] and leaving them around [on the unit]." The need to ensure updated service plans were available to staff, were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 8 and Staff 29 (ED) on 04/24/25 at 5:14 pm. They acknowledged the findings. 4. Resident 12 moved into the memory care community in 12/2024 with diagnoses including unspecified dementia. The service plan, dated 03/06/25, and Temporary Service Plans, dated 01/02/25 through 01/24/25, were reviewed. Observations were made of the resident and staff were interviewed. The service plan was not reflective of the resident's status and/or did not provide clear direction regarding the delivery of services in the following areas: * Specific details relating to hallucinations or delusions (e.g. what they relate to and what staff need to do when the resident exhibits them); * Resident's preference of staff to negate shower refusals; * Fall interventions including room checks every one to two hours as the resident spills food and/or beverages in his/her unit; * The utilization of the pull cord to request staff assistance; * Caregivers to apply lotion to his/her head and face daily; * Dressing assistance to help negate multiple layers of clothing; and * Where the resident's unit key was located. The need to ensure updated service plans were available to staff, were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 5:14 pm. They acknowledged the findings. 2. Resident 14 moved into the memory care community in 02/2025 with diagnosis including dementia with anxiety, Alzheimer's disease, vertigo, and bowel and urinary incontinence. The resident's record, including the most recent service plan, dated 02/05/25 with handwritten updates dated on 03/11/25, progress notes, dated 02/05/25 through 04/24/25, and Temporary Service Plans were reviewed, observations were made, and interviews with staff were conducted. The following was identified: The resident's service plan was not reflective of residents current needs and did not provide clear direction regarding the delivery of services in the following areas: * Behaviors and interventions; * Sleep routine including insomnia and daytime naps, and resident preferences; * Evacuation status; * Pain interventions and how to identify; * Reluctant to accept care; * Elopement status; * Bathing status and assistance needed; * Cognition status; * Dressing and undressing status; * How the resident communicates; * Eating, meals, and hydration status and instruction to staff; * Ability to eat independently; * Vision and use of glasses; * Personal hygiene status and assist level needed; * Mobility status; * Toileting status; * Transferring status; * Hospice services; * Use of weighted blanket and weighted stuffed animals; * Resident environmental preferences including temperature; * Interest in housekeeping tasks and when a staff member danced with him/her; and * Behaviors related to after the resident's spouse visited the facility. The need to ensure the resident's service plan was reflective of resident's current needs and provided clear direction regarding the delivery of services was reviewed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 6:36 pm. They acknowledged the findings.

1: Service plan binders have been purged and new updated service plans in the cottages. Corrective Action for Resident 13 service plan updated to reflect the noted deficit areas. Use of floor mattress; the method of taking medications; crushed vs whole; Use of partial dentures and instructions for cleaning and storing them; and transfer status. service plan placed in cottage for staff to have available. Once the update was completed the new service plan was placed in the service plan binder in an appropriate cottage. Corrective Action for Resident 14 service plan updated to reflect the noted deficit areas. Behaviors and interventions; sleep routine including insomnia and daytime naps, and resident preferences; evacuation status; pain interventions and how to identify; reluctant to accept care; elopement status; bathing status and assistance needed; cognition status; dressing and undressing status; how the resident communicates; eating, meals, and hydration status and instruction to staff; ability to eat independently; Vision and use of glasses; personal hygiene status and assist level needed; Mobility status; toileting status; transferring status; hospice services; use of weighted blanket and weighted stuffed animals; resident environmental preferences including temperature; interest in housekeeping tasks and when a staff member danced with her; and behaviors related to after the resident's spouse visited the facility. Once completed the new service plan was placed in the cottage in the service plan bind to be available for care staff to have access. Corrective action for resident 11 service plan was updated to reflect the noted deficit areas: Behaviors and what triggers the behaviors; behavior interventions; caregiving staff to apply powder after assisting the resident to the restroom; Ability to verbalize pain; the use of a bed and chair alarm; Chronic skin condition; Transfers best when she has something to hold on to (e.g. grab bar): Preferred beverages; Staff are to assist with brushing his teeth after every meal; and staff assistance needed for daily telephone calls to spouse. Service plan was updated and a copy was placed in the Service plan binder in the appropriate cottage for care staff to have access. Corrective action for resident 12 service plan was updated to reflect the noted deficit areas: Specific details relating to hallucinations or delusions (e.g. what they relate to and what staff need to do when the resident exhibits them); Resident's preference of staff to negate shower refusals; Fall interventions including room checks every one to two hours as the resident spills food and /or beverages in her unit; the utilization of the pull cord to request staff assistance; Caregivers to apply lotion to her head and face daily; dressing assistance to help negate multiple layers of clothing; and there the resident's unit key was located. 2: Correction to the system to prevent future occurrences has been implemented by Care plan service binder review once a week making sure the updated care plans are in the service binders and the old service plans are place in the hard chart. Updates via TSP are to be reviewed each clinical review and placed in the service plan binder if the interventions are to be added to the service plan during the 90 day review period. 3. Service plan and TSP to be reviewed each clinical review and weekly checks to make sure all Service plan binders are up to date. 4. Clinical review team consistent of RN, LPN, Administrator, RCC, and RCM or a subset of the listed persons.

Based on interview and record review, it was determined the facility failed to ensure service plans provided clear direction to staff regarding the delivery of services, for 4 of 8 sampled residents (#s 5, 6, 17 and 20) whose service plans were reviewed. This is a repeat citation Findings include, but are not limited to: Residents 5, 6, 17 and 20 were admitted to the facility with diagnoses including dementia. Interviews with staff, and review of service plans showed the plans were not reflective of the residents' current behaviors and did not provide clear direction to staff in the following area: * Affectionate physical behaviors towards other residents. Interviews with multiple staff on 09/09/25 and 09/10/25 revealed that Residents 5 and 6 were frequently observed together, holding hands, hugging, or kissing. Staff also reported that Residents 6 and 17 were physically affectionate with each other, and that Residents 5, 6 and 17 were observed together on multiple occasions. In addition, staff reported Resident 20 was in a relationship with two other sampled residents. Service plans for residents 5, 6, 17 and 20 did not address these affectionate physical behaviors or provide staff clear direction on interventions, monitoring, or appropriate staff response. The need to ensure resident service plans were reflective of current behaviors and provided direction to staff was discussed with Staff 2 (Chief Operating Officer), Staff 3 (Director of Nursing), Staff 10 (Admissions Coordinator) and Staff 29 (Administrator) on 09/10/25.

1. A relationship log has been distributed to direct care staff and placed within the care plan binder for reference. Additionally, resident relationship information has been integrated into the Point of Care electronic medication administration record (eMAR) system. 2. Staff are required to document observations related to resident relationships during each shift to facilitate ongoing monitoring and identification of any changes. 3. The relationship log and associated documentation will be reviewed weekly during the clinical stand-up meeting to ensure consistency and accuracy in reporting. 4. Clinical staff shall maintain responsibility for oversight and discussion of resident relationship documentation during regularly scheduled clinical meetings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 5 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to: Resident 1, 2 and 3's current service plans were reviewed during the survey. The service plans lacked evidence 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 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings.

1. C262: A service plan team will be established on 6/17/24, consisting of the Resident Care Manager, LPN, Business Office Manager, Resident Care Coordinator, Facility Administrator, and the Cottage Captain. 2. C262: Weekly service plan meetings will be held on Wednesdays. 3. C262: The Resident Care Manager will conduct weekly monitoring. 4. C262: The Administrator will conduct weekly monitoring to ensure the service plan team is in place.

4. Resident 4 was admitted to the memory care facility in 04/2023 with diagnoses including dementia with behavioral disturbances. Observations of the resident, interviews with staff, review of the resident's 05/29/24 evaluation and service plan, 03/01/24 through 06/03/24 temporary service plans, progress notes, physician communications, hospital discharge summaries, home health visit notes, and incident investigations were reviewed. The following was revealed: The following short-term changes of condition lacked documentation of progress noted at least weekly, and/or documentation of resolution: * 03/02/24: Resident-to-resident altercation; * 03/03/24: Fall; * 03/06/24: Fall with skin injury; * 03/11/24: New medication; * 03/16/24: Resident-to-resident altercation; * 03/19/24: Resident-to-resident altercation; * 04/01/24: Resident-to-resident altercation; * 04/05/24: Resident-to-resident altercation; * 04/10/24: Resident-to-resident altercation; * 04/10/24: ER visit; * 04/19/24: Resident-to-resident altercation; * 04/24/24: Resident-to-resident altercation; and * 05/22/24: Resident-to-resident altercation. On 06/05/24 at 10:20 am, additional information was requested. During an interview with Staff 8 (LPN) on 06/05/24 at 2:00 pm, she stated she reviewed the record and was unable to find documentation that the short term changes of condition had been monitored until resolved. The need to ensure short term changes of condition were monitored weekly through resolution was discussed with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings. No further information was provided. 5. Resident 3 was admitted 09/2023 with diagnoses which included dementia and diabetes. Observations and an interview with the resident, interviews with staff, review of the service plan dated 04/08/24, incident investigations, and progress notes dated 03/01/24 through 06/03/24 were reviewed. The following short-term changes of condition lacked documentation of progress noted at least weekly and/or documentation of resolution: * 03/22/24: Fall; * 03/30/24: New medication; * 04/10/24: Resident-to-resident altercation; * 04/23/24: Fall; * 05/11/24: Fall; and * 05/23/24: Fall. In an interview on 06/05/24 at 1:55 pm, Staff 8 (LPN) reviewed the resident's record and acknowledged the findings. No further information was provided. The need to ensure Resident 3's short-term changes of condition had documentation to reflect monitoring at least weekly to resolution Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings. 2. Resident 5 moved into the memory care community in 03/2020 with diagnoses including vascular disease. Review of the 03/01/24 through 06/03/24 progress notes and temporary service plan, dated 05/24/24 through 05/29/24, showed  Resident 5 experienced the following short-term changes of condition: * 03/21/24 - "Resident has a light yellow discoloration on left knee."; * 03/28/24 - "Resident had discoloration on [his/her] left forearm and hand."; * 05/02/24 - "Resident has 2 small discoloration spots on right knee"; * 05/10/24 - "discoloration on left arm."; * 05/24/24 - a fall and emergency department visit; * 05/24/24 - skin tear to the right arm and open area to back of head; and * 05/25/24 - an emergency department visit due to pain. The facility lacked documented evidence changes of condition were monitored, with progress noted at least weekly through resolution. The need to ensure each of Resident 5's short term changes of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings. 3. Resident 6 moved into the memory care community in 03/2024 with diagnoses including Alzheimer's disease. Review of the 03/21/24 through 06/01/24 progress notes and temporary service plans, dated 04/29/24 through 05/24/24, showed Resident 6 experienced the following short-term changes of condition: * 04/16/24 - Bruising "right lower butcheek and right arm"; * 04/27/24 - Rash on the right groin area; * 04/29/24 - Skin tear on the elbow; * 04/30/24 - " Resident's abdomen has about a baseball sized bruise with like a road rash or rug burn on the inside."; * 05/12/24 - " Open area on right side of buttocks"; * 05/25/24 - A fall with skin tear on the right upper elbow and left ring finger swollen; * 05/26/24 - "Bruising/discoloration to arm and bottom"; and * 05/27/24 - Splint on the left ring finger. The facility lacked documented evidence changes of condition were monitored, with progress noted at least weekly through resolution. The need to ensure each of Resident 6's short term changes of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short-term changes of condition had determined what action or intervention was needed, actions or interventions were communicated to staff on all shifts and progress was documented weekly until resolution for 5 of 6 sampled residents (#s 2, 3, 4, 5, and 6). The facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed for 1 of 4 sampled residents who experienced a significant change of condition (# 2). Findings include, but are not limited to:   1. Resident 2 was admitted to the facility in 02/2023 with diagnoses including cerebrovascular accident (stroke) and dementia without behaviors. Review of the 03/02/24 through 06/02/24 progress notes, and physician orders showed Resident 6 experienced the following short-term changes of condition: * On 03/16/24, Staff 13 (MT) documented Resident 2 had a choking incident during a meal and his/her diet texture was downgraded from regular to mechanical soft. * There was no documented evidence the facility determined actions or interventions and communicated to staff on each shift on swallow precautions and how staff should respond if they observed Resident 2 experiencing a choking episode. * On 04/30/24, Staff 13 documented Resident 2 had another choking incident during a meal and his/her diet texture was downgraded to puree. * There was no documented evidence the facility evaluated the resident, referred to the facility nurse, actions or interventions determined, documented and communicated to staff on each shift on swallow precautions and how staff should respond if they observed Resident 2 experiencing a choking episode, and the changes of condition were monitored. The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the need to ensure there was documentation significant changes of condition were evaluated, referred to the nurse and the service plan was updated as needed, was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings. No further information was provided.

1. C270: Facility staff received training on 6/12/24 regarding the reporting of areas/injuries of unknown origin. Staff also received training on identifying changes of condition. Service plans were subsequently updated for residents 2, 4, 5, and 6. 2. C270: The Resident Care Manager/Resident Care Coordinator will notify the LPN of all resident changes of condition. 3. C270: The LPN will notify the RN via telephone and email of any significant changes of condition. 4. C270: The Facility Administrator will conduct weekly monitoring.

Based on observation, interview, and record review, it was determined the facility failed to ensure actions or interventions were determined, documented, and communicated to staff on each shift, and interventions were monitored for effectiveness with weekly progress noted to resolution for 1 of 3 sampled residents (# 7) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to: Resident 7 moved into the facility in 09/2022 with diagnoses including Alzheimer's disease. During the acuity interview on 11/12/24, the resident was identified to be involved in resident to resident altercations. Review of the resident's clinical record including progress notes from 08/12/24 through 11/11/24, the 11/01/24 service plan, and temporary service plans (TSPs) from 08/16/24 thru 10/30/24 was completed during the survey.      a. The 11/01/24 service plan indicated the resident "has a history of altercations with other residents." Staff to redirect the resident "during times of increased behaviors by offering food, fluids, and offering other activities." Review of the resident's clinical record, noted the resident was involved in eight resident to resident physical altercations between 08/16/24 and 11/11/24. The facility failed to determine and document what actions or interventions were needed for the repeated resident to resident altercations and failed to monitor the interventions for effectiveness. During the survey, the resident was observed wandering throughout the facility and required staff assistance for bathroom use. Additionally, the resident needed reminders and escorting to meals and activities. b. Review of the resident's clinical record showed the following: * 08/18/24: On a new psychotropic medication; * 09/12/24: A resident to resident physical altercation; and * 09/17/24: Bruise on right thigh, buttock and scratch on left armpit area. There was no documented evidence weekly monitoring had been completed through resolution. During an interview on 11/13/24 at 2:58 pm, Staff 8 (LPN) confirmed the skin injury was not monitored. The need to ensure the facility determined, documented, and communicated to staff on each shift actions or interventions that were needed, interventions were monitored for effectiveness, and weekly progress was noted until resolution for short-term changes of condition was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer) and Staff 3 (Facility RN) on 11/14/24 at 11:09 am. Staff acknowledged the findings.

2. Resident 13 moved into the memory care facility in 08/2024 with diagnoses including dementia without behavioral disturbance and anxiety. Review of the resident's clinical record, including progress notes, dated 01/22/25 through 04/23/25, the 03/27/25 service plan, incident reports, and Temporary Service Plans, dated 12/16/24 thru 03/28/25, were reviewed during the survey. The following short-term changes of condition lacked documentation the facility communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved: * 01/06/25: Fall; * 02/15/25: Open area on the left leg; and * 03/28/25: Injury from fall resulting two abrasions and back pain. The need to ensure the facility communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 1:50 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition were identified, actions or interventions were determined, documented, and communicated to staff on each shift, and interventions were monitored for effectiveness with weekly progress noted, through resolution, for 3 of 3 sampled residents (#s 11, 13 and 14) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 14 moved into the memory care community in 02/2025 with diagnosis including dementia with anxiety, Alzheimer's disease, vertigo, and bowel and urinary incontinence. On 04/23/25, during the acuity interview, the resident was identified to require meal assistance and to receive hospice services. The resident's record, including the most recent service plan, dated 02/05/25 with handwritten updates dated 03/11/25, progress notes, dated 02/05/25 through 04/24/25, and Temporary Service Plans were reviewed, observations were made, and interviews with staff were conducted. The following was identified: a. On 02/05/25, the facility documented Resident 14's weight to be 91.5 pounds. On 03/19/25, the resident was noted to weigh 83 pounds, and indicated from the time of move-in on 02/05/25 through 03/19/25, Resident 14 experienced a total body weight loss of 8.5 pounds, or 9.28% of his/her total body weight in one month. This constituted a severe weight loss. On 04/24/25, the following was noted: At 10:55 am, Staff 30 (MT) stated the resident had experienced noticeable weight loss since s/he moved in, and Staff 30 was trying to obtain an order from hospice for scheduled nutritional shakes. At 11:33 am, Staff 8 (LPN) stated since the resident was on hospice the facility was not monitoring the resident for weight loss. At 12:19 pm, Resident 14 was observed to be assisted with meal intake by Staff 30 that included hand over hand assistance with eating and cueing the resident to initiate eating. The resident consumed approximately 75% of the meal served. At 7:25 pm, Staff 3 (RN) stated the resident was on hospice therefore, she was not monitoring the resident's continued weight loss. b. Behavior changes that included: * 02/06/25: Resident 14 will "take and hide roommates" belongings; * 02/06/25: "wanders in other resident rooms [and] goes through [their] belongings"; * 02/10/25: "will pour water on other residents"; * 02/10/25: Resident will "place self on floor"; * 02/14/25: The resident "flipped the TV"; * 02/20/25: "...resident was hitting staff and other residents..."; * 02/11/25: Exit seeking behaviors that included "...trying to get out of cottage and explained to staff escape plan..."; * 02/10/25: Resident 14 will go to the bathroom in common area; * 02/10/25: "will take [feces] out of toilet and play with it"; * 02/12/25: The resident took a "hand full of feces [and] spread [it] all over the living room and dining room"; * 02/23/25: Insomnia; * 02/24/25: "will take off clothes in common area and go to the bathroom on the floor"; * 02/24/25: "resident plays with [his/her] feces and will wipe on the wall"; * 03/24/25: " ...a few days ago ... [the] resident smeared feces all over another [resident's] room"; and * 04/11/25: The resident was found out of bed and "messing with [his/her] roommate".   c. Skin conditions that included:   * 02/14/25: Skin tear to back of hand; and * 03/17/25: "red marks on right shoulder". The facility lacked documented evidence the changes of condition noted above were identified, and actions or interventions were determined, documented, and communicated to staff on each shift, and interventions were monitored for effectiveness, and the service plan was updated to reflect the interventions. The need to ensure the facility evaluated, determined, documented, and communicated the determined action or intervention to staff, monitored and documented progress until resolution was reviewed with Staff 8 and Staff 29 (ED) on 04/24/25 at 6:36 pm. They acknowledged the findings. 3. Resident 11 moved into the memory care facility in 04/2023 with diagnoses including dementia and psychotic disturbance. The resident's record, including the service plan available to staff, dated 09/23/24, Temporary Service Plans, dated 01/02/25 through 04/03/25, and progress notes, dated 01/20/25 through 04/23/25, were reviewed, observations were made, and interviews with staff were conducted. The following short-term changes of condition lacked documented evidence the facility determined actions or interventions, communicated the determined actions or interventions to staff on each shift, and/or documented weekly progress until the condition resolved: * Verbal resident to resident altercations occurring on 02/23/25 and 04/11/25; and * Bruising of unknown cause on multiple dates on the resident's left or right hand. The need to ensure the facility documented determined actions or interventions, communicated the actions or interventions to staff on each shift, and/or monitored the change through resolution was discussed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 5:14 pm. They acknowledged the findings.

1: Corrective action for Resident 14 new orders received from hospice with hospice service plan added to residents current care plan to offer and encourage eating for enjoyment without concerns for weight loss or decline in ADL's due to the terminal diagnosis. Weekly monitoring of skin issues by nursing staff. Corrective action taken for Resident 13 correct the documentation of monitoring skin issues with adding assessment, and if needed add to weekly skin monitoring by nursing staff. Increase the documentation of intervention's and effectiveness of the interventions in place. Corrective actions taken for residents 11 corrected with reporting bruising of unknown cause to APS and follow up with assessment by nursing staff and adding resident to weekly skin sheet. Corrective action for verbal residents to resident place new intervention during mealtimes and assess for effectiveness of interventions place. 2: The corrective action to the system for short term change of conditions, is hiring a new LPN to split the building and decrease the workload of the full time LPN in the building. 3: Checks on Short term change of conditions will be done multiple times a week during clinical review meeting. 4: Administrator or RN during clinical review will preform audits.

2. Resident 4 was admitted to the memory care facility in 04/2023 with diagnoses including dementia with behavioral disturbances. Observations of the resident, interviews with staff, review of the resident's 05/29/24 evaluation and service plan, 03/01/24 through 06/03/24 temporary service plans, progress notes, physician communications, hospital discharge summaries, home health visit notes, and incident investigations were reviewed. The following was revealed: A progress note and incident investigation, dated 05/08/24, indicated Resident 4 had an altercation with another resident and the other resident sustained an injury. "911 was called and resident [Resident 4] was taken to [hospital] for evaluation ..." On 05/20/24, Staff 8 (LPN) and Staff 7 (Regional LPN) evaluated the resident in the hospital for his/her possible return to facility and "resident safety ..." Resident 4 returned to the facility on 05/22/24 (14 days after admit to hospital). The hospitalization constituted a significant change in condition for which an assessment by the facility RN was required. There was no documented evidence the facility RN conducted an assessment. During an interview with Staff 8 (LPN) on 06/05/24 at 4:30 pm, she stated the resident had been sent to the hospital because the facility was concerned for both his/her safety and the safety of other residents. She acknowledged a facility RN assessment had not been completed when the resident was readmitted back to the facility. The facility RN was not available during the survey for interview. The need to ensure facility RN assessments were completed with significant changes in condition was reviewed with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings. No further information was provided. 3. Resident 6 was admitted to the memory care facility in 03/2024 with diagnoses including Alzheimer's disease. Observations of the resident, interviews with staff, review of the resident's 05/09/24 evaluation and service plan, 03/21/24 through 06/01/24 temporary service plans, progress notes, physician orders and incident investigations were reviewed. The following was showed: A progress note and incident investigation, dated 05/25/24, indicated Resident 6 had a fall which resulted in "a skin tear to right upper elbow and left ring finger, left ring finger also very swollen." A 05/25/24 physician visit note indicated left ring finger was dislocated and required a splint on the ring finger for three weeks. The injury represented a significant change in condition which required a facility RN assessment. There was no documented evidence the facility RN conducted an assessment. During an interview with Staff 1 (Administrator) on 06/05/24 at 3:30 pm, she acknowledged a facility RN assessment had not been completed when the resident had a significant injury which resulted in a major deviation of the resident's health or functional abilities. The facility RN was not available during the survey for interview. The need to ensure facility RN assessments were completed with significant changes in condition was reviewed with Staff 1 and Staff 8 (LPN) on 06/05/24. 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 was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 3 of 4 sampled residents (#s 2, 4 and 6) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 02/2023 with diagnoses including cerebrovascular accident (stroke) and dementia without behaviors. Observations of the resident, interviews with staff, review of the resident's 05/01/24 service plan, progress notes, and hospice visit notes were reviewed. The following was showed: A progress note dated 04/30/24, indicated Resident 2 had a choking incident during a meal and his/her diet texture was downgraded to puree. This was the second choking episode and diet texture change in seven weeks and constituted a significant change in condition for which an assessment by the facility RN was required. There was no documented evidence the facility RN had completed an assessment to include findings, resident status and interventions made as a result. During an interview with Staff 1 (Administrator) on 06/05/24, she acknowledged a facility RN assessment had not been completed when the resident had a second episode of choking which resulted in another downgrade of diet texture to puree and constituted a significant change of condition which resulted in a major deviation of the resident's health or functional abilities. The facility RN was not available during the survey for interview. The need to ensure facility RN assessments were completed with significant changes in condition was reviewed with Staff 1 and Staff 8 (LPN) on 06/05/24. They acknowledged the findings. No further information was provided.

1. C280: The facility will conduct staff training on significant and short-term changes of condition. 2. C280: The LPN will communicate with the RN via email and telephone when changes of condition need to be addressed by the RN. 3. C280: The LPN will meet with the RN weekly to review resident changes. 4. C280: The Administrator will ensure that resident changes are communicated daily and weekly.

Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 1 of 1 sampled resident (#3) who received subcutaneous injections by a facility unregulated assistive person (UAP). Findings include, but are not limited to: Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions and outcomes pursuant OAR 851-045 including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client. During the acuity interview on 06/03/24, Resident 3 was identified to be administered a subcutaneous injection once weekly by a facility UAP. Resident 3's MARs from 05/01/24 through 06/03/24 revealed subcutaneous injections had been given by Staff 11 (MT/CG) and Staff 12 (MT/CG). Review of the nursing delegation binder found no documented evidence all elements of the initial delegation were completed for Staff 11 and Staff 12. Additionally, the RN assessment to determine Resident 3's condition was stable and predictable, one of the criteria for delegation of a nursing procedure, was not completed and/or documented. Staff 3 (RN), the facility nurse, was not present and available during the survey. The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 was reviewed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings. No further information was provided.

1. C282: The LPN will ensure that all RN delegations are completed in their entirety. 2. C282: The LPN/Administrator will meet with the RN to review the delegation form and add a section that explains the resident's condition as stable and predictable. 3. C282: The LPN will review the delegation binder/documents weekly and monthly, and for all new staff during orientation. 4. C282: The Administrator will follow up monthly.

Based on interview and record review, it was determined the facility failed to review the Acuity Based Staffing Tool (ABST) for each resident no less than quarterly and to use the results to develop and routinely update the facility's staffing plan. Findings include, but are not limited to: The facility's ABST was reviewed and discussed with Staff 2 (Chief Operating Officer), Staff 1 (Administrator) and Staff 23 (Business Office Manager) on 06/04/24. The facility had implemented the ODHS ABST tool. All three staff members confirmed the facility did not utilize the ABST for each resident no less than quarterly, to routinely update the staffing plan, nor did the ABST inform the facility the total number of weekly minutes required to meet the 24-hour scheduled and unscheduled needs of residents. Instead, the facility's staffing plan was generated by Staff 1 based on her prior work experience as a nurse. Staff 23 stated she was scheduled to start ABST training with the Department on 06/06/24. The need to ensure residents' ABST was reviewed no less than quarterly and the tool was used to develop and update the facility's staffing plan was discussed with Staff 1, Staff 2 and Staff 23 on 06/05/24. They acknowledged the findings. No further information was provided.

1. C361: The facility will request access to the ABST for the Resident Care Manager and the Business Office Manager. 2. C361: The facility will designate the Resident Care Manager and the Business Office Manager to complete the ABST by 8/5/2024. 3. C361: The Resident Care Manager will update the ABST daily and weekly with any changes or new move-ins. 4. C361: The Administrator will ensure compliance by 8/5/2024.

Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months and to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: On 06/04/24, fire drill and fire and life safety records for the previous six months were requested. Review of the documentation provided revealed there was no documented evidence the facility provided fire and life safety training for staff and conducted unannounced fire drills on alternate months. The need to provide fire and life safety instruction to staff and conduct unannounced fire drills on alternate months was discussed with Staff 2  (Chief Operating Officer) and Staff 5 (Maintenance) on 06/04/24. They acknowledged the findings. No further information was provided.

1. C420: The facility was cited for lacking documented fire training prior to the start of the current Maintenance Director. 2. C420: The current Maintenance Director is conducting unannounced drills every other month and written training during the months without live drills. 3. C420: The Maintenance Director will evaluate and continue to conduct training and drills monthly as per the OAR. 4. C420: The Administrator will monitor compliance monthly.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed about fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 06/04/24 at 11:30 am. There was no documented evidence residents were provided fire and life safety procedure training within 24 hours of admission to the facility and were being re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. The need for residents to be instructed about fire and life safety procedures within 24 hours of admission and at least annually thereafter, per the OFC, was discussed with Staff 2 (Chief Operating Officer) and Staff 5 (Maintenance) on 06/04/24. They acknowledged the findings. No further information was provided.

1. C422: All resident service plans will be updated to reflect the residents' ability and mental capability to participate independently in evacuations or emergency situations. 2. C422: This update will be completed at move-in and annually, as per Oregon Administrative Rule. 3. C422: The Resident Care Manager will evaluate residents at move-in and annually to ensure training is being completed. 4. C422: The Facility Administrator will monitor compliance weekly for new move-ins.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to: Refer to C 231, C 361, C 420, and C 422.

Z-142: See Tags C231, C361, C420, C422

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 200, C 231, and C 363.

Refer to C200,C231, and C363

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 limited to: Refer to: C 152, C 200, C 260, C 242, C 355, C 360, and C 363.

1. Refer to C152, C200, C260, C355, C242, C360, C363

Based on observation, interview, and record review, it was determined the facility failed to ensure health services were consistently provided in accordance with the licensing rules of the facility. Findings include, but are not limited to: Refer to C 242, C 252, C 260, C 262, C 270, C 280 and C 282.

Z-162: See Tags C242, C252, C260, C262, C270, C280, C282

Based on observation, interview, and record review, it was determined the facility failed to ensure health services were consistently provided in accordance with the licensing rules of the facility. Findings include, but are not limited to: Refer to C 260, C 270, and C 295.

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

Refer to C200, C231, C363

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

1. Refer to C260, C303

Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan for 2 of 6 sampled residents (#s 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: Resident 4 and 5's current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident. The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings.

1. Z163: The residents' service plans will be updated to reflect the specific meal plan and hydration plan by 7/30/2024. 2. Z163: The Resident Care Manager, Resident Care Coordinator, and LPN will make the updates. 3. Z163: The Facility Administrator will ensure compliance through weekly meetings until completed. 4. Z163: Facility Administrator

Based on interview and record review, it was determined the facility failed to develop individualized activity plans for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose activity plans were reviewed. Findings include, but are not limited to: Service plans and evaluations were reviewed for Residents 1, 2, 3, 4, 5 and 6. There was no documented evidence individualized activity plans were developed based on the residents' activity evaluations that reflected each residents' activity preferences and needs. The need to ensure the facility developed individualized activity plans was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings.

Z-164:   See Tag C242.

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 3 of 3 sampled residents (#s 7, 8 and 9) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident service plans and activity assessments were reviewed. There was no documented evidence the facility had fully evaluated and developed individualized plans based on the residents': * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions, if necessary. The need to ensure the facility developed individualized activity plans based on the activity evaluation was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer) and Staff 3 (RN) on 11/14/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure required postings were posted in a routinely accessible and conspicuous location to residents and visitors.  Findings include, but are not limited to: The facility was divided into three memory care units: Pine, Oak, and Maple. On 09/09/25, observations of the facility's main lobby and separate MCC cottages revealed an absence of the following required postings: * The name of the administrator or designee in charge; * The current facility staffing plan; * Resident Rights and Protections, including the LGBTQIA2S+ Rights and Protections; and * LGBTQIA2S+ Nondiscrimination Notice. In an interview with Staff 29 (Administrator) and Staff 2 (Chief Operating Officer) on 09/09/25 at 4:04 pm, they reported being unaware of the specific LGBTQIA2S+ postings required, or that all required postings needed to be accessible to residents in each separate cottage. The need to ensure required postings are posted in a routinely accessible and conspicuous location for residents and visitors was reviewed with Staff 2, Staff 3 (RN), Staff 10 (Admissions Coordinator), and Staff 29 on 09/10/25 at 1:00 pm. They acknowledged the findings.

1. All mandated postings have been duly installed in the primary lobby area of the facility as well as within each individual cottage. LGBTQ policy and protections the Residents Rights and Protections, Manager on duty, and the daily staffing schedule. 2. A comprehensive list of required postings will be furnished to front desk personnel. Front desk coverage is maintained seven days per week. 3. The designated front desk staff member shall perform a weekly walkthrough inspection to verify that all postings remain properly displayed and clearly visible. 4. The Facility Administrator

Based on interview and record review, it was determined the facility failed to ensure residents' rights to have a safe and homelike environment for multiple unsampled residents related to 1 of 1 sampled residents (#14) reviewed. Findings include, but are not limited to: Resident 14 moved into the memory care community in 02/2025 with diagnosis including dementia with anxiety, Alzheimer's disease, and bowel and urinary incontinence. The resident's record, including the most recent service plan, dated 02/05/25 with handwritten updates on 03/11/25, progress notes, dated 02/05/25 through 04/24/25, and temporary service plans were reviewed. Interviews with staff were conducted and the following was identified: * 02/09/25: Resident 14 was "getting anxious and pacing around [Resident 14] was affecting [his/her] roommate with this behavior"; * 02/10/25: The resident "will take [a bowel movement] out of toilet and play with it"; * 02/10/25: Public urination in common areas; * 02/12/25: The resident took a "hand full of feces [and] spread [it] all over the living room and dining room"; * 02/13/25: Resident 14 was "trying to get in [his/her] roommates bed"; * 02/24/25: The resident "plays with [his/her] feces and will wipe [it] on the wall"; * 02/24/25: The resident "will take off [his/her] clothes in common area and go to the bathroom on the floor"; * 03/24/25: "a few days ago" the resident "smeared feces all over another [resident's room]"; and * 04/11/25: The resident was found out of bed and "messing with [his/her] roommate". The resident's above noted exhibiting ongoing behaviors impacted the ability of multiple unsampled residents to live in a homelike environment. The need to ensure residents rights and the right to live in a safe and homelike environment was reviewed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 6:36 pm. They acknowledged the findings.

1: For Resident 14 the corrective actions taken was to update the service plan and provide increased education on interventions. Staff report effectiveness of interventions that redirect the noted behaviors. Increased the rounding on Resident 14 and increased the time needed on the ABST. 2: System updated with new requirements during Clinical review. 24-hour book reviewed the clinical team to discuss each behavior and possible interventions. Education provided on requirements of interventions for behaviors that affect not only the residents but also the other residents that live within the facility. 3: Clinical Team during clinical review to note if new behaviors have been identified and if current interventions are effective in mitigating the negative results of behaviors. Also review each QI of the month for the next three months than move to quarterly. 4: Clinical team during clinical review to complete the checks. Clinical reviews have LPN, RN, Administrator, RCC, and RCM. or a subset of listed members depending on the needs of the facility.

2. During the third revisit survey conducted from 09/08/25 through 09/10/25, multiple staff interviews identified that the facility failed to consistently maintain an adequate supply of incontinent briefs necessary to meet residents' needs and to ensure their rights to dignity and respect. Interviews with staff between 09/08/25 and 09/10/25 revealed that due to the facility's failure to provide adequate incontinent briefs, staff were required to use briefs belonging to other residents when supplies were depleted. As a result, residents were frequently placed in the wrong size incontinent briefs, compromising dignity, comfort, and placing them at risk for impaired skin integrity. The need to ensure the facility maintained an adequate supply of incontinent supplies was discussed with Staff 2 (Chief Operating Officer), Staff 3 (Director of Nursing), Staff 10 (Admissions Coordinator), and Staff 29 (Administrator) on 09/10/25.

Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that protected privacy and dignity and provided a safe and homelike environment for multiple unsampled residents. This is a repeat citation. Findings include, but are not limited to: 1. The MCC cottages were designed such that the kitchens were open to resident dining rooms via a pass-through counter from which meals were served and caregivers had an unobstructed line of sight to the dining room. The dining room opened to a common area where residents and visitors could lounge and watch television. a. On 09/08/25 at 4:55 pm, Staff 24 (CG) stood at the kitchen counter and loudly asked Staff 36 (CG), who was escorting a resident from the common area to the dining room, whether two unsampled residents had had a bowel movement that day, using first names to identify those residents. Approximately 14 residents were seated in the dining room awaiting dinner service, and may have overheard the remarks. b. On 09/08/25 at 4:17 pm, Staff 24 was observed providing ADL care for an unsampled resident with the bathroom door and the door to the room open to the common hallway; anyone passing by could potentially view the resident toileting. The need to ensure the facility ensured residents received services in a manner that protected privacy and dignity and provided a safe and homelike environment was reviewed with Staff 2 (Chief Operations Officer), Staff 3 (Director of Nursing), Staff 10 (Admissions Coordinator), and Staff 29 (Administrator) on 09/10/25 at 1:00 pm.  They acknowledged the findings.

1.      Staff education provided to all staff members on the rights of the residents. Focusing on privacy and HIPAA compliance. Proper communication of residents activities including bowel and bladder logs to document without sharing to the cottage. 2. A. As part of the onboarding process, all newly hired employees will be required to review and formally acknowledge the residents' rights policy. Orientation will include a guided tour of the cottages, during which staff will be shown the designated locations for personal care supplies. B. All the cotteges have been given a Supplies sheet for eacch resident, to be turned into management as needed for personal supplies. 3. The facility shall conduct annual training for all staff members to reinforce the importance of safeguarding residents' rights and to ensure continued compliance with applicable standards. 4. This corrective action plan is being overseen and implemented under the direction of the Facility Administrator.

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 7 and 8) and multiple unsampled residents who received dining services. Findings include, but are not limited to:   1. The surveyor observed on 11/13/24 at 12:23 pm, Staff 26 (CG) and Staff 27 (CG) serve lunch to residents in the Pine unit. There were 16 residents in the dining room for lunch. During the observations, Staff 26 and 27 donned gloves without performing hand hygiene. Staff  27 picked items including napkins from the floor and then served food to Resident 7 and other residents with the same gloves. Similarly, Staff 26 touched her hair with gloved hands multiple times and then served food without changing gloves. Staff 26 and 27 failed to change gloves between clean and dirty tasks and perform hand hygiene prior to donning gloves. The above observations were discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer) and Staff 3 (Facility RN) on 11/14/24 at 11:09 am. Staff acknowledged the findings. 2. The following was observed during two meal services. a. During lunch service on 11/13/24 Resident 8 was observed to walk up to an unsampled resident and take a corn muffin from his/her plate. A caregiver observed this and redirected the resident, allowing Resident 8 to continue to eat the muffin that had been on the other resident's plate. The caregiver did not replace the unsampled resident's meal after Resident 8's fingers had been on his/her plate. b. On 11/13/24 prior to lunch, Resident 8 was observed rubbing his/her teeth, tongue and around the inside of his/her mouth with his/her fingers. The resident then touched his/her blanket and the couch he/she was lying on in the common area. No hand hygiene was provided to Resident 8 and multiple unsampled residents prior to breakfast on 11/23/24 or lunch on 11/13/24. The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer), Staff 3 (RN), and Staff 8 (LPN) on 11/14/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident medications were administered as ordered by the physician for 1 of 1 sampled resident (# 6) whose medication orders were reviewed. Findings include, but are not limited to: Resident 6 was admitted to the facility in 03/2024 with diagnoses including lactose intolerance. Resident 6's physician orders and 08/01/25 through 09/10/25 MARs were reviewed. Resident 6 had an order for Lactaid Fast Act 9,000 (for lactose intolerance) to chew and swallow one tablet by mouth three times daily as needed with first bite of dairy product. The MAR instructed staff "to check at each mealtime if dairy is being given. If yes, give PRN Lactaid Fast Act as ordered with meals for lactose intolerance." Review of the 08/01/25 - 08/31/25 MAR showed 27 meals contained dairy. Of the 27 meals, Lactaid was administered five times. Review of the 09/01/25 - 09/10/25 MAR showed eight meals contained dairy. Of the eight meals, there was no documented evidence Lactaid was administered. In an interview, on 09/10/25, Staff 8 (LPN) confirmed the MAR lacked documentation that the medication was administered as ordered. On 09/10/25, Witness 1 reported it was an ongoing struggle to have the facility administer Lactaid as ordered. Witness 1 stated they repeatedly had to remind staff that the resident required Lactaid when consuming dairy. The need to ensure all medications were administered as ordered was discussed with Staff 2 (Chief Operating Officer), Staff 3 (Director of Nursing), Staff 10 (Admissions Coordinator), and Staff 29 (Administrator) on 09/10/25.

1. Educational guidance and counseling have been provided to the medication technicians. The relevant physician's order has been amended to require that medication technicians verify the presence of dairy in meals during their routine checks. 2. The Culinary Department shall include a clear notification on the daily menu identifying any meals that contain dairy products, in order to support dietary compliance and resident safety. 3. Menus will be subject to daily evaluation to ensure accuracy and alignment with dietary restrictions and resident care plans. Dialy clinical meeting will address that the MAR is being documented correctly. 4. The Culinary Director will be responsible for implementing and maintaining menu corrections. Oversight and follow-up will be conducted by the Facility Administrator to ensure continued compliance.

Based on interview and record review, it was determined the Administrator failed to maintain a current Residential Care Facility Administrator license. Findings include, but are not limited to: Record review showed Staff 29 (Administrator) had been serving in the role of Administrator since 01/13/25. On 09/12/25, the facility's policy analyst confirmed that Staff 29 serving as the Administrator, did not hold a current Residential Care Facility Administrator license. The facility failed to have an Administrator with a current Residential Care Facility Administrator license as required.

1. As of September 22, 2025, the facility is under the leadership of a duly licensed Administrator. 2. In instances where communication challenges arise with the Health Licensing Agency (HLA), the facility shall engage the Department of Human Services (DHS) at an earlier stage to facilitate timely resolution and regulatory support. 3. The facility will ensure proactive coordination with the appropriate licensing authorities when a new license is required, including timely submission of all necessary documentation and adherence to applicable regulatory timelines. 4. Oversight and implementation of these procedures will be supported by the Management Company in collaboration with the Facility Administrator.

Based on observation, interview, and record review, it was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: The facility was divided into three memory care units: Pine, Oak, and Maple. At the time of the survey the facility was home to 53 residents: 19, 17 and 17, respectively. The facility used the Department ABST to document resident care needs and develop its staffing plan. The data in the ABST was reviewed on 09/09/25 at 11:45 am. The facility provided a copy of the staff schedule and the time card record which included the dates and times that all staff worked for the weeks of 08/24/25 - 08/30/25 and 08/31/25 - 09/06/25. The following deficiencies were identified: * The ABST indicated the facility needed 9 direct care staff during the day shift (6:00 am - 6:00 pm) to meet the scheduled and unscheduled needs of the residents across the three units. The facility failed to provide the required number of staff on 09/6/25 and half of the day shift on 09/03/25. * The ABST indicated the facility needed 7 direct care staff during the night shift (6:00 pm - 6:00 am) to meet the scheduled and unscheduled needs of the residents across the three units. The facility failed to provide the required number of staff on 09/01/25 and 09/02/25. Interviews with staff and Staff 2 (Chief Operating Officer) on 09/09/25 indicated that, though the facility scheduled the required number of staff each day on each shift, there were staff who called out and the facility was not always able to find someone to fill in on that shift. The need to ensure the facility provided a sufficient number of staff on each shift to meet the needs of the residents was discussed with Staff 2, Staff 3 (Director of Nursing) and Staff 29 (Administrator) on 09/10/25. No additional information was provided.

1. A. Service plans have been reviewed and updated accordingly.         B. ABST has been updated to match services provided in the residents Care Plan. C. Staff schedule has been updated per the ABST.         D. Currently the ABST is requiring 3 staff in each cottege during the day. We are staffing 3 staff in each cottege with a float for added tasks.         E. The NOC shift ABST is requiring 2 staff in each cottege. We are currently staffing 2 staff in each cottege with 2 extra staff at night.   2. A. The Aquity Based Staffing Tool (ABST) is being continuously updated to reflect current staffing levels. At present, the system indicates that each cottage is staffed with three personnel during daytime hours and two during the overnight shift. B. The Facility has entered into agreements with local staffing agencies to ensure adequate staff coverage and to asddress any staffing short falls. 3. The ABST will be reviewed and updated on a weekly basis, or more frequently as staffing needs evolve, to maintain accurate and compliant reporting. 4. Oversight of these staffing measures and ABST updates is the responsibility of the Facility Administrator.

Based on interview and record review, it was determined the facility failed to ensure the ABST (Acuity Based Staffing Tool) was updated before each resident moved in, at least quarterly, and following changes of condition, to determine appropriate staffing levels to address activities of daily living and other tasks related to care, for 3 of 4 sampled residents (#s 12, 13 and 14). Findings include, but are not limited to: a. Review of clinical records, including service plans for Residents 14, revealed the facility's ABST tool was not updated before move-in, quarterly and when there was a significant change of condition to reflect the residents' care needs, in order to ensure the ABST accurately determined the needed staffing level. b. Review of clinical records, including service plans for Residents 12 and 13 revealed the facility's ABST tool was not updated quarterly to reflect the residents' care needs, in order to ensure the ABST accurately determined the needed staffing level. On 04/24/25, the need to ensure the ABST tool was updated at least quarterly and following changes in condition was discussed with Staff 8 (LPN) and Staff 29 (ED). They acknowledged the findings.

1: Corrective action was to update and add the missing or incorrect hours into the system immediately upon discovery of the deficiency 2: System corrected to add a duo check system that makes sure a corrected ABST is completed with each move-in, significant change of condition and during quarterly service planning. 3: The system will be evaluated once weekly during IDT meeting. 4: The Administrator and Nursing lead will be responsible in making sure the new system remains updated with the correct information

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation for each resident was reviewed and updated no less than quarterly at the same time the resident's service plan was updated, for 2 of 2 sampled residents (#s 15 and 16) and multiple unsampled residents. This is a repeat citation. Findings include, but are not limited to: The facility used the Department ABST to document resident care needs and develop its staffing plan. The data in the ABST was reviewed on 09/09/25 at 11:45 am. The following were identified: a. Resident 15 was admitted to the facility in 06/2025. The resident's service plan was reviewed and updated on 09/04/25. The resident's ABST evaluation was last reviewed on 06/12/25 and was not reviewed and updated along with the service plan. b. Resident 16 was admitted to the facility in 05/2025. The resident's service plan was last reviewed and updated on 07/16/25 but the resident's ABST evaluation was last reviewed and updated on 05/31/25. c. Resident 5 was admitted to the facility in 03/2020. The resident's service was last reviewed and updated on 06/15/25, but the resident's ABST evaluation was last reviewed and updated on 05/31/25. d. The date that each resident's ABST evaluation was reviewed or updated was reviewed. Of the 53 current residents reviewed, 42 resident ABST evaluations had not been reviewed and updated in the last 90 days (quarterly). The findings were reviewed with Staff 29 (Administrator), Staff 3 (Director of Nursing) and Staff 2 (Chief operating Officer) on 09/11/25. No additional information was provided.

1. The ABST documentation has been fully updated and is current as of this reporting period. The Facility is staffing to the current ABST. 2. Daily stand-up meetings now include participation from the Service Plan Team to ensure comprehensive review and communication of: o Any material changes to resident care plans o Care plans currently undergoing formal review In support of this process, the facility has implemented a centralized Excel-based tracking tool that identifies all care plan update due dates. This tool is accessible to relevant personnel and is intended to promote timely compliance and interdepartmental coordination. 3. These procedures are conducted on a daily basis during the scheduled stand-up meeting. 4. Facility Administrator

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 242, C 260, C 270, and Z 164.

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. This is a repeat citation. Findings include, but are not limited to: Refer to C 260 and C 270.

Refer to 260,270, and 280

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. This is a repeat citation. Findings include, but are not limited to: Refer to C 200 , C 260 , and C 363 .

1. See Paln of Correction

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to: The licensee is responsible for the operation of the MCC and the provision of person-directed care that promotes each resident's dignity, independence and comfort. This includes the supervision and overall conduct of the staff. During the third revisit survey, conducted 09/08/25 through 09/10/25, administrative oversight to ensure adequate resident care and services was found to be ineffective, as the facility remained out of compliance and continued to receive additional citations. This demonstrated an ongoing pattern of noncompliance and ineffective administrative oversight. Refer to deficiencies in the report.

1. Refer to C355.

The findings of change of ownership survey, conducted 06/03/24 through 06/06/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. 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 06/06/24, conducted 11/12/24-11/14/24, 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 C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 06/06/24, conducted 04/23/25 through 05/07/25 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 06/06/24, conducted 09/08/25 through 09/10/25 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily 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 fourth re-visit to the re-licensure survey of 06/06/24, conducted 11/17/25 through 11/18/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in clean and good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: 1. On 12/27/23, observations of the facility main kitchen identified the following: a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following: * Interior and exterior of the oven and stove top; * Interior and exterior of the "Duke" oven; * Walk-in refrigerator and freezer shelving and flooring; * Interior and exterior of the reach-in refrigerator; * Stainless steel open shelving; * Ceiling vents; * Walls and ceiling; * Mixer and mixer stand; and * A box fan. b. Two kitchen staff were sampled for evidence of current food handler cards. Staff 3 (Dietary Supervisor) and Staff 4 (Chef), failed to have documented evidence of a current food handler card. Staff 2 (Chief Operations Officer) reported Staff 3 and Staff 4 would be pulled from the kitchen until they could complete the Oregon food handler course. c. Ice machine scoop was stored inside the ice machine. d. Multiple items inside the standing and walk-in refrigerators were not labeled, dated, and/or covered. 2. On 12/27/23, observations of the facility three kitchenettes identified the following: a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following: * Interior and exterior of multiple cabinets and drawers; * Interior of multiple reach-in refrigerators and freezers; * Multiple toasters; and * Drawers below ovens. b. Unserved and plated meals were observed on counters without covers, for extended periods of time, and open to potential contamination. c. Universal workers, who provided care to residents, were observed to not use aprons during food plating and service.   On 12/27/23, the food handling and storage concerns, and the areas in need of cleaning were reviewed with Staff 2 and Staff 3. They acknowledged the findings.

C 240 1a -Deep cleaning of the kitchen was completed including the interior and exterior of the stove, walk-in refrigerator and freezer, stainless steel shelving, ceiling vents, walls and ceilings, and all appliances. -Cleaning schedule was implemeted for daily and weekly cleaning tasks. C240 1b Staff 3 and staff 4 have completed the Oregon food handler course and now have current food                handler cards. This was accomplished on 12/27/23. C 240 1c Ice machine scoop was taken out and placed in a Cambro for the time being. A wall mounted ice machine scoop caddy has been ordered and will be installed and said scoop will be placed there from now on. C240 1d All items were removed and thrown away. Kitchen staff have since attended an in-service on 1/17/24 and been trained on the importance of using labels correctly, and the correct procedure when storing all food products. C240 2a -A deep cleaning of the cottage kitchens have been completed includinginterior and exterior cabinets and shelves, small applainces, interior and exterior of the refrigerator and drawyers under the stove. -A cleaning schedule was implemented in all of the cottages and will be instected by the dietary supervisor weekly. - An in-service was conducted on 1/17/24 to discuss the importance of keeping a clean and sanitary kitchenette and the importance of cleaning as you go. c240 2b Care staff have attended an in-service on 1/17/24 and have been trained on the importance of covering, dating and proper storage of all food products. Plastic film, labels and food storage containers have been purchased as well to promote proper protocol. The Dietary Supervisor will check on this daily to make sure it's done correctly. C240 2c Universal workers attended an in-service training session on 1/17/24 discussing the importance of wearing an apron during food plating and service. Z142 Please see the previous plan of corrections for C240 item 1 and 2

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 240.

2-Please refer to Plan of Correction.

The findings of the kitchen inspection, conducted 12/27/23, 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 12/27/23, conducted 06/03/24 through 06/04/24, are documented in this report. The facility was found to be 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 interview and record review it was confirmed the facility failed to carry out medication and treatment orders as prescribed.  Findings include: In an interview on 9/16/2022, Staff #1 (S1) reported the following: *A medication audit by the facility RN showed Resident #1 (R1) went without prescribed medications for 4 days. *The medication was entered into R1's Medication Administration Record (MAR) as not administered because it had not been received from the pharmacy, when the medication had been entered incorrectly under a different resident's name. *Record review of the facility's incident report and self report to Adult Protection Services dated 9/7/2022 supported S1's statement. Record review on 9/16/2022 of Resident #1-2 (R1-2)s MARs revealed the following: *R1 missed scheduled mediations for 4 days because they were not in the facility. *R2's MAR reflected the addition of R1's medication in error, however R2 never received the medication. On 9/16/2022, findings were reviewed and acknowledged by S1. Plan of Correction: Facility LPN did an internal investigation into the mixup with medications, several Med Techs were involved.  All received in-service training on receiving and updated medications in MARs.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 9/16/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

2. Resident 3 was admitted to the facility in 02/2022. a. Review of  Resident 3's new move in evaluation dated 02/09/21 revealed the following elements were not addressed: * Social interests; * List of current Diagnosis; * Visits to health practitioner, ER, hospital or NF in the past year; * Decision making abilities; * Pain: Pharmaceutical and non-pharmaceutical interventions, including how the person expresses pain or discomfort; * Nutrition habits, fluid preferences and weight if indicated; * Indicators of nursing needs including potential for delegated nursing tasks; * Fall risk or history; * Complex medication regimen; * Recent losses; * Elopement risk or history; and * Smoking, ability to smoke safely. b. Resident 3's move-in evaluation failed to include the following elements: * Environmental factors that impact a resident's behavior; and * Personality, including how the person copes with change and changing situations. The need to ensure new move-in evaluations contained all required elements was discussed with Staff 1 (Administrator) on 03/15/22. She acknowledged the findings. 3. Resident 4 was admitted to the facility in 03/2021 with diagnoses including Alzheimer's and arteriosclerosis. Review of Resident 4's most recent quarterly evaluation, dated 10/25/21 indicated the document was not updated timely (within three months). On 03/16/22 the need to complete timely updates of quarterly evaluations was discussed with Staff 1 (Administrator). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 3 and 5) and failed to complete quarterly evaluations for 1 of 1 sampled resident (#4). Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 02/2022 with diagnosis including Alzheimer's disease and hypertension. a. Resident 5's move-in evaluation failed to address the following elements: * Cultural traditions and preferences; * Vital signs; * Cognition, including: orientation, confusion and decision making abilities; * Ability to use the call system; * Housekeeping and laundry; * Transportation; * Nutrition habits; fluid preferences and weight if indicated; * List of treatments: types, frequency and level of assistance needed; * Nursing needs, including potential for delegated nursing tasks; * Emergency evacuation ability; * Complex medication regimen; and * Unsuccessful prior placements. b. Resident 5's move-in evaluation failed to include the following elements: * Environmental factors that impact a resident's behavior; and * Personality, including how the person copes with change and changing situations. The failure to include all required elements and to address all required elements in the move-in evaluation was discussed with Staff 1 (Administrator) on 03/15/22. She acknowledged the findings.

1. Administrator and RN,RCM now have in place a Evaluation check off list and the updated Oregon Evalution. .  New format for move-ins will be the responsibility of the Administator and RN, RCM to check the evalutions for all new move-ins, before resident is admitted.. 2. All Evaluations for move-ins will be in place before resident move-in with the team to ensure it is complete, Adminiistrator/ RN/RCM, to check the Oregon Evaluation.    3.Administrator will check every move-in and final check will be the RN signing off and reviewing the evaluations that are complete. Oversight by Administrator will be continued as a move-in pending weekly or monthly. 4.Administrator will oversee the move-in process and evalutions will be  double checked before move-in happens.  RN and RCM will check evalutions and sign off that the  resident is ready for move-in for the final check. This will include Activity Evaluations, and all medical information is completed. Activity evaluations are also in place, with training on the evalution process with activity director.

Based on interview and record review, it was determined the facility failed to create a service plan for 2 of 2 sampled residents (#s 3 and 5) who recently moved into the facility and update the service plan quarterly for 1 of 1 sampled resident (# 4) whose service plan was reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 02/2022 with a diagnosis of dementia. During an interview with Staff 1 (Administrator) on 03/14/22, she stated service plans for new residents were not created until the resident had been in the facility for 30 days. The survey team reviewed the OAR with Staff 1 and she acknowledged the facility was not in compliance during this review. The need to ensure service plans were created before residents moved into the facility was discussed with Staff 1 on 03/14/22. She acknowledged the findings. 3. Resident 4 was admitted to the facility in 03/2021 with diagnoses including Alzheimer's and arteriosclerosis. Review of Resident 4's most recent quarterly service plan, dated 10/25/21 indicated the document was not updated timely (within three months). On 03/16/22 the need to complete timely updates of quarterly service plans was discussed with Staff 1 (Administrator). She acknowledged the findings. 2. Resident 5 was admitted to the facility in 02/2022 with diagnosis including Alzheimer's disease and hypertension. There was no documented evidence the facility completed an initial service plan prior to move-in. On 02/21/22 the resident had an injury fall with fractured left hip. The resident returned to the facility on 03/04/22. The resident had a decline in ADL ability. This constituted a significant change of condition. The RN completed an assessment of the resident's condition and noted changes in ADL care. There was no documented evidence a service plan was updated after the significant change of condition. The need to ensure residents had an initial service plan developed that provided clear direction regarding the delivery of services, included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and was updated after the resident experienced a significant change of condition was discussed with Staff 1 (Administrator) and Staff 4 (RN) on 03/15/22. They acknowledged the findings.

1. Administrator and RCM will set up a system for tracking service plans to alert the clinical team, who is due for quarterly, and 30 day.  Administrator, and RCM/will notify RN of changes of condition.  RCM and Administrator will talk with med-techs to review the information for the change of condition, When RN is notified RN will note in service plan the change. 2.Administrator and RCM with clinical team input will use the tracking system, keep updated on all service plans quartely, 30 day and change of conditions 3. Administrator and RCM, will check weekly for any service plans that may need TSP, and changed.. This will ensure the service plans are timely. 4. Administrator per regulation and oversite including RCM will be responsible for oversight of the service plans and review the weekly service plan audit to keep service plans up to date. Administrator and RCM/RN during the weekly clinical meetings will review service plans and residents needing updates..

2. Resident 1 was admitted to the facility in 03/2020 with diagnoses including dementia. Review of facility charting notes indicated Resident 1 returned from a hospital stay on 12/17/21 with "...a large spot of caked on blood on [his/her] right cheek." On 12/18/21 following a shower it was noted "Cleaned wound and placed a small band aid on [his/her] cheek." There was no documented evidence the injury had been monitored until resolved. The need to monitor changes of condition to resolution was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 3 (Resident Care Manager) on 03/15/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to monitor and document weekly progress of short-term changes of condition until the condition resolved for 2 of 5 sampled residents (#s 1 and 5) whose records were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 02/2022 with diagnoses including Alzheimer's disease. A review of the resident's charting notes and MARs dated 02/14/22 through 03/14/22 indicated the following short term changes of condition: * New move-in on 02/14/22; * New medication (Seroquel) on 02/15/22; * New medication (Depakote) on 02/16/22; * Behaviors on 02/15/22; * Injury fall resulting in fractured left hip on 02/21/22; and * Non-injury fall on 03/06/22. There was no documented evidence the facility determined and documented what action or intervention was needed for the changes of condition, communicated the interventions to staff and documented staff instructions or interventions were not made part of the resident record with weekly progress noted until the condition resolved. The need to ensure short term changes of condition were monitored, weekly progress noted, and interventions were developed and reviewed for effectiveness was discussed with Staff 1 (Administrator) on 03/15/22. She acknowledged the findings.

1.Administrator during the Clinical meetings which are daily  will meet with RCM/RN to review each resident for any changed health issues. This meeting will be done to ensure residents change whether short term or Long term.  Weekly meeting will enhance the wellness of residents change of condition. RN/RCM will use white board to help RN to see how the residents are doing and to track residents on-going. 2. Daily and weekly updates on residents will be done  during clinical meetings when reviewing each resident from QuickMar.  RN/RCM/Administator will be responsible for the oversight of meetings, and new change conditions of the residents. 3. At the end of each week RN/RCM/RCC will  review any changes in condition when discussing residents to RCM/Med-techs, to meetng their care needs. 4. Administrator and the RN/RCM will discuss in daily clinicals which residents need addressed and or how they are doing.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 5 sampled residents (#5) whose orders were reviewed. Findings include, but are not limited to: Resident 5 moved into the facility in 02/2022 with diagnoses which included hypertension and Alzheimer's disease. a. Resident 5's MARS, reviewed from 02/14/22 (move-in) through 02/21/22 (day resident left facility) and admission orders dated 02/11/22 revealed the following medications were not administered as prescribed: * Gabapentin 100 mg, give daily at night was administered at 8:00 am; * Lidocaine Patch every 12 hours was not administered; and * Melatonin 3 mg daily was not administered. On 03/15/22, Staff 11 (MT), reviewed the MARs and confirmed the resident had not received Melatonin or Lidocaine patches. From 02/14/22 through 02/21/22 there was no documented evidence the Melatonin and Lidocaine patches were administered as prescribed and there were no other signed physician orders for discontinuation of these orders. b. On 03/03/22 the facility received electronically signed hospital discharge orders. The resident returned to the community on 03/04/22. The following prescribed medications were not administered as ordered: * From 03/04/22-03/14/22, Gabapentin 100 mg, give daily at night was administered at 8:00 am; * Docusate/Senna 50 mg twice daily, was not administered until 03/08/22; * Levothyroxine 137 mcg daily, was not administered until 03/08/22; * Melatonin 6 mg daily, was not administered until 03/09/22; and * Quetiapine 25 mg daily, was not administered until 03/07/22. MAR exception notes indicated "waiting on delivery" and "order not approved". During an interview with Staff 4 (RN) and Staff 3 on 03/15/22 they acknowledged the facility did not have an effective system to ensure physician orders were signed, medications were obtained in a timely manner and administered as prescribed.

1. Administrator will meet with RCM/RN, to set up training with Med-techs om orders including what to do if orders are not complete RCM/RCC will assist in training med-techs along with Administrator reviewing the training and RN oversight with medication  training on Orders, MARS, Faxing. 2.RCM will do weekly audits on MARS and check orders coming in.  Orders will have 3 way checks for review to ensure signed Orders or changes.  this will include RN.RCM/Administator/ Med-tech. 3. Clinical orders will be reviewed daily for completed physicians orders, Med-techs to notify RN/RCM/Administrator for any issues with orders so they can be completed correctly. 4. Administrator RCM/RN will be respsonsible for all physcians orders and correct orders,including physician signature and any descrepancies that may occur will be corrected through physicians or Pharmacy.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs provided clear medication specific instruction and resident specific parameters for administration of PRN medications for 2 of 5 sampled residents (#s 1 and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1's February 1st through March 14th 2022 MARs were reviewed. Resident 1 had orders for: *Enema as needed for constipation; and *Polyethylene Glycol 3350 powder as needed for constipation. There were no resident specific parameters or instructions directing non-licensed staff when to use which PRN medication and in which order. The need to ensure MARs were accurate and included clear directions for as needed medications to direct non-licensed staff was reviewed with Staff 1 (Administrator), Staff 4 (RN), and Staff 3 (Resident Care Manager) on 03/15/22. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 02/2022 with diagnosis including Alzheimer's disease. Resident 5's February 1st through March 14th 2022 MARs identified the following PRN medications lacked resident specific parameters and instructions for non-licensed staff on when to use the medication and lacked the order of administration for multiple PRN medications used to treat the same condition. * PRN Mylanta and PRN Pepto Bismol for upset stomach; * PRN Tylenol and PRN hydrocodone for pain; and * PRN olanzapine for agitation. The need to ensure MARs included clear directions and parameters for non-licensed staff was reviewed with Staff 1 (Administrator) and Staff 4 (RN) on 03/15/22. They acknowledged the findings.

Administrator and RCM/RCC will check orders on quickmar to review the medications are given  correctly and, training will be through RCC/RCM. RN is working on PRN parameters and Med-techs will be trained to report to RCM/RCC and Administrator any missed meds. Clinical meetings daily through Emar will be reviewed to see if meds are missing. RCM to run medication exception for all residents daily.This will ensure orders, treatments, and any medications that have not been given or on wait list, can be addressed immediately,to prevent harm. 2. Medication audit Administrato will meet daily with RCC.RCM oversight for quality assurance, Any missed medications notify Administrator, and RN, to review. 3. Daily evalutations will be reviewed  for orders, and any unusal  medications that need a RN to oversee and verify. Administrator will be notified and RCM/RCC. 4. RCC oversees the medication room with RCM and RN oversight, Administrator will review any medications that need attention with clinical team for resolutions.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when they were installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to: The interior of the RCF was toured on 03/14/22 at approximately 1:30 pm. The surveyor observed a fireplace in the common area living room where a resident could come in incidental contact with it. The fireplace was on and felt hot to the touch. The surface temperature of the heater was in excess of 160 degrees F when measured with the surveyor's digital thermometer. There were similar fireplaces installed in each separate cottage. The surveyor asked Staff 1 (Administrator) on 03/14/22 to turn off the fireplace and ensure it was deactivated. The fireplace was off for the remainder of the survey. The fireplaces were discussed with Staff 1 (Administrator) on 03/14/22. She acknowledged the need to address the risks associated with the fireplaces.

Maintenance is covering the fireplaces with screens, This action will keep residents  from getting close when fireplace is to hot.  Maintenance will report to Administrator if the fireplaces seem hotter than the temperature 120.Maintenance will check temperatures 2x's weekly to ensure the correct temperatures. 2. Maintenance will continue to monitor all 3 fieplaces and keep tracking the system to ensure safety of residents who like to get close to the fireplaces. 3. Weekly checks and documentation to show temperatues to maintan the fireplaces for resident safety. Maintenace will report any issues to Administrator. 4.Maintenance will be responsible to report temperatures. This can be done at daily stand-up what the temperatures  are by the fireplaces, Action will be taken if temperture are higher than 120, Administrator will contact the appropriate vendor to assist in the temperatures .

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system for security purposes and to alert staff when residents exited the facility. Findings include, but are not limited to: On 03/14/22, it was observed the exit doors that residents used to access an interior outdoor courtyard for each cottage had exit door alarms but were not activated to alert the staff when the doors were opened. In Oak Cottage, the door alarm would sound if the door was held open for five second. In Pine Cottage, the door alarm would activate if the door was open for 15 seconds and Maple Cottage door alarm would activate if the door was open for 30 seconds. In an interview on 03/14/21, Staff 1 (Administrator) confirmed the doors to the courtyard did not have an alarm that alerted staff when a resident went outdoors. The need to ensure the facility had an exit door alarm or other acceptable system for security purposes or to alert staff when residents exited the facility was discussed with Staff 1 on 03/14/22 . She acknowledged the findings.

1.Administrator has taken action with maintenance for the exit doors alarms to be within the 3 second for possible alarm exiting. Sentinel alarm company has been informed to come evaluate the issue and fix. 2.Maintenance and Administrator will test the doors weekly to check alarms and make sure they are within the parameters for exit timing. Maintenance will oversee with Administrator to get the  appropriate company to look at the alarms. 3. Maintenance to test doors weekly for appropriate time for the alarm to go off.  Maintenance will document days tested and report to Administrator. 4. Maintenance, Administrator, to follow-through on timing of door alarms.  Maintenance will call for company to repair when needed, and report issue to Administator.  If Alarm is not working staff will need to watch doors, for any risks.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for non-healthcare areas for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 540 and C 555.

1.Per Oregon State reulations under Administrative responsibilbities, The Administrator must follow both the licensing rules for the facility and these rules, as outlined in the memory care regulations and assisted living regulations.Administrator has been consulted, and assistiing in learning how the regulations and licensing are implemented. 2.  Administrator training has been completed in the process of Memory Care licensure and regulations for Assisted Living.. 3. Administrator will audit weekly through clinical area's and  RCM to ensure the complinance in all departments. 4. Administrator will be oversight in the area's and meet with staff to assist in any questions, and or area's of concern. . Administrator will check clincials area's for completeness.

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 252, C 260, C 270, C 303 and C 310.

1. Administrator and RCM have set up times for Hydration at snack times and with meals,for hydration. Water with the meals and will be  available at all times. Residents will be offered water and juices with snacks and also at all 3 meals. 2. Caregivers will be trained on hydration changes with residents through RCM and Administrator to offer water at snack times and meals. RCM will montior the caregivers on hydration measures. 3.RCM will do daily walkthrough to see how the hydration program is going to ensure the residents are getting fluids appropriately and offered daily. 4. . Administrator will work with RCM for compliance with hydrations and water with juices offered at meal times.Administrator will do daily rounds to monitor the hydration for residents.  RCM will report if hydration is not getting met, through staff daily .

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 2 of 5 sampled residents (#s 3 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in February of 2022 with a diagnosis including dementia. The facility failed to create a nutrition and hydration plan for Resident 3. There was no documented evidence the facility provided staff instructions related to individualized nutrition and hydration status and needs. In an interview with Staff 1 (Administrator) on 03/15/22, she revealed the nutrition and hydration plan was created when the first service plan was completed after the first 30 days of move in. The need to develop individualized nutrition and hydration plans as part of the initial service plan was discussed with Staff 1 on 03/15/22. She acknowledged the findings. 2. Resident 5 was admitted to the facility in February 2022 with a diagnosis including Alzheimer's disease. Failure to thrive was noted on the resident's new move-in evaluation. There was no documented evidence the facility provided staff instructions related to individualized nutrition and hydration status and needs. On 03/14/22, Staff 1 (Administrator) reported the facility does not create an initial service plan until the resident had been in the community for 30 days. The nutrition and hydration plan was part of the service plan that was created on the resident's 30th day of residing in the community. The need to develop individualized nutrition and hydration plans as part of the initial service plan was discussed with Staff 1 and Staff 3 (Resident Care Manager) on 03/14/22. They acknowledged the findings.

1, Administrator will work with RCM/RCC/RN for updated information on service plans regarding Hydration, including nutrition. All service plans will be reviewed for hydration and nutrition for service plan compliance. Each service plan is individulized for nutrition, hydration, along with  nursing services. 2. RCM and Administrator will review service plans to assess any changes in hydration and nutrition.  Monthly audit on all service plans for completeness, and as they arise. 3. Clinical team will review on the 30 day service plan and 90 day service plans, as condition changes for resident 4. RCM/RCC/RN with Administrator will oversee the information regarding nutrition, and hydration for the new move-in and quarterly service plans..

Based on 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, for 2 of 5 sampled residents (#s 3 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 02/2022 with a diagnosis including dementia. Resident 3's life history evaluation offered some information about the resident's interests, but the facility had not fully evaluated the resident's: * 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 was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. The need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1 (Administrator) on 03/15/22. She acknowledged the findings. 2. Resident 5 was admitted to the facility in 02/2022 with a diagnosis including Alzheimer's disease. A document titled "Life Story" offered some information about the resident's past and current interests, however the facility had not fully evaluated the resident's: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; * Activities that could be used as behavioral interventions, and * There was no initial service plan or activity plan created for the resident that documented the resident's activities of preference. The need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1 (Administrator) and Staff 6 (Activities Director) on 03/15/22. They acknowledged the findings.

1. Activities has a new evaluation assessment for residents with person centered activites and emotional well-being.  Assessment will be completed on each resident. The evaluation/assessment will inlcude spirtual, cultural sensory, physicial activites and level of participation, life history, likes and dislikes,. 2. Administrator will oversee activites, and audit the new format to assure the activities director understands how  to use the evaluation and  capture the residents activity levels. 3. Activites will be notified when resident has a change of condition and re-assess the level of participation as of change of condition. Administrator will meet with activites and notify activites of the change. 4. Administrator will review activities. assessment/evalution upon new move-ins and resident changes in level of care.  .

2. Resident 3 was admitted to the facility in 02/2022 with a diagnosis including dementia. Resident 3's record had documented behaviors including yelling, hitting staff and aggression towards staff. Resident 3 did not have a service plan and there was no additional documentation which addressed the behaviors and there were no individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 03/15/22 the need to develop individualized behavior plans for residents with behaviors was discussed with Staff 1 (Administrator). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident and others in the community and include information and instructions for staff on the service plan, for 2 of 2 sampled residents (#s 3 and 5) who had documented behaviors. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 02/2022 with a diagnosis including Alzheimer's disease. Resident 5's charting notes documented behaviors including exit seeking, wandering in other resident rooms and refusing to leave, crying, disorientation and agitation. On 03/15/22, Resident 5 was observed upset and becoming agitated when Staff 19 (CG) intervened with reassurance and redirection. Staff 19 was observed spending a significant amount of time with the resident until s/he was calmed. On 03/15/22, Staff 19 reported s/he was a new employee, didn't know the resident very well, there wasn't much information regarding the resident and s/he was just doing the best s/he could with the resident. Resident 5 did not have an initial service plan and there were no temporary service plans that documented additional information and resident specific interventions to assist staff in minimizing the negative impact of the behaviors. On 03/15/22 the need to develop individualized behavior plans for residents with documented behaviors was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. Administrator to work with RCM/RCC to assist staff in behavioral measures for resident. RCM will be contacting a outside behavior specialist for memory care to come and  in-service the staff. Staff will be showen on how to walk away and come back later when resident is upset and threatening. Service Plans will be addressed for behavior and interventions 2. In-service training from a behavioral specialist and complete service plans with addressing behaviors for staff.  Staff then will read service-plan for clarity for how to handle behaivors. Administrator to assist RCM in getting staff behavior training. 3.  Administrtator and clinical team will meet to discuss residents with behavior in the meeting daily. RCM/RCC and assitance from RN, will discuss the evaluation for residents with behaviors. 4. Administrator, clinical team RCC/RCM/RN, will complete service plans are updated with behaviors when needed, during there daily clinical meetings. .

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation areas was of sufficient weight and design to not aid in elopement. Findings include, but are not limited to: On 03/14/22, a tour of the facility courtyard revealed round metal patio tables and chairs which were easily moveable and not of sufficient weight or design to prevent elopement. On 03/15/22, the need to ensure furniture in the outdoor recreation areas was of sufficient weight and design to not aid in elopement was discussed with Staff 1 (Administrator) and Staff 6 (Maintenance Director). They acknowledged the findings.

1. Administrator and Maintenance are in contact with the Owner/Operator to get patio furniture non-removable. The facility fence is 8 feet,which is elevated more than the required 6 feet. Administrator and Maintenance will get professional assistance for evaluation of the patio furniture. 2. Maintenance will report to Administrator if any furniture has issues with repositioning on patio. 3. Once the furniture has been evaluated by a professional and owner/operator  Maintenance can report any deficiencies with the furniture to Administartor, if there is a failure.   4. Maintenance will oversee the furniture of the community and report any issues to the Administrator who will contact the Owner/Operator.

The findings of the initial licensure survey, conducted 03/14/22 through 03/16/22, 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 re-visit to the re-licensure survey of 03/16/22, conducted 07/13/22 through 07/14/22, are documented in this report. It was determined the facility was in compliance with 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.