Pelican Pointe

Based on observation, record review, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:   Observation occurred of the main kitchen 06/04/24 through 06/05/24 and the following was identified: a. The following areas were in need of cleaning and/or repair: * Can opener blade had debris and was peeling; * Kitchen entrance/exit doors and frames had black scuffs, gouges, and peeling paint, which exposed the door surfaces; and * Two open areas were observed around the sprinkler heads above the preparation area and the steam table. b. Poor infection control practices observed, but not limited to:   * Dining room had preset tables with food contact surfaces of cutlery exposed to potential contamination; and * Two cooks and/or servers with beards lacked coverings for their facial hair. During an interview on 06/04/24 at 11:00 am, Staff 3 (Executive Chef) stated the Fire Marshal had come to test the sprinkler integrity and had taken the covers. Staff 1 (ED) stated that the facility would reach out to the Fire Marshal and question what best practice was for the openings. No additional information was provided at time of survey exit. On 06/05/24 at approximately 9:25 am, the above areas were reviewed with Staff 1 who acknowledged the identified areas.

1. A) A new can opener blade will be ordered and current blade will be replaced. Entrance/exit doors and frames in the kitchen will be cleaned, sanded, repaired where necessary and repainted. ESD will reach out to Fire Marshal and request to have the sprinkler head cover plates re-installed or replaced. B) All cutlery is now being rolled inside napkins before being placed on tables. Beard nets have been ordered for kitchen staff that have facial hair. 2. Dining staff will receive additional training in OAR 333-150-000 as well as OAR 411-054-0030. Executive Chef and Sous Chef will monitor these areas on a continual basis. 3. These areas will be evaluated on a daily basis. 4. It will be the responsibility of the Executive Chef, Sous Chef and ED to ensure that the corrections are completed and monitored for continual compliance.

The findings of the kitchen inspection, conducted 06/04/24 to 06/05/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 06/05/24, conducted on 10/17/24, are documented in this report. The facility was found in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to: The Residential Care Facility (RCF) was toured on 06/03/24. The following were not posted as required: * Name of administrator or designee in charge posted by shift; * Facility staffing plan; and * Ombudsman poster. During an interview on 06/03/24 Staff 1 (ED) reported she was unaware that separate postings were required for the RCF and assisted living communities. The need to ensure all required items were posted was reviewed with Staff 1 (ED) on 06/03/24. She acknowledged the findings.

1) A request from the local Ombudsman Office has been made for additional posters for the RCF. The name of the Administrator/Designee as well as the facility staffing plan has been posted in the RCF. 2) Once received, Ombudsman posters will be placed in the RCF. Facility Administrator/Designee as well as facility staffing plan will be housed in frames on the wall of the RCF reception area. 3) This area will be evaluated monthly to ensure compliance. 4) The ED and BOM are responsible to ensure corrections are completed and evaluated.

Based on interview and record review, it was determined the facility failed to develop and implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview with Resident 1 on 06/03/24 s/he reported that the heating and cooling system in his/her unit hadn't been working right since s/he moved into the facility four weeks prior. Resident 1 stated s/he had told "the helpers" several times and wasn't sure who else to tell. In an interview with Staff 5 (Environmental Services Director) on 06/04/24 he reported he was aware of Resident 1's heating and cooling system malfunction and that there was an electrician coming to address the issue on 06/06/24. Staff 5 reported he had no documentation of the work order in his log, and he had not communicated to Resident 1 regarding the resolution of his/her complaint. The need to ensure the facility developed effective methods of responding to and resolving resident complaints was discussed with Staff 1 (ED) on 06/06/24. She acknowledged the findings.

1) Review of the Grievance Policies and Procedures. Residents will be reminded of the availability and location of the Grievance Binder. ED will implement monthly Town Hall meetings to be conducted approximately 1 week after monthly Resident Council meetings to discuss resident concerns/suggestions that were brought up in the Resident Council meeting. 2. Policy and Procedure will be implemented and followed to include a twice weekly review of the Grievance Binder by the ED. All grievances/complaints entered into the Grievance Binder will have a written response within 10 days. Responses will be logged into the binder. Resident Council meetings will be followed by a monthly Town Hall meeting to discuss concerns. Written Resident Council notes and written Town Hall notes will be entered into the Grievance Binder. 3) The Resident Grievance Binder will be checked twice weekly. Resident Council notes will be reviewed monthly and responded to during the Monthly Town Hall meeting. 4) It is the responsibility of the ED to ensure corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to: During the survey, conducted 06/03/24 through 06/06/24, there were no observations of individual or group activities being provided for residents in the Residential Care Facility (RCF). Upon entrance, an activity calendar was requested and the calendar provided was specifically for the Assisted Living facility and not the RCF. In an interview with an unsampled resident on 06/05/24 at 2:30 pm, s/he stated that there had been no activities taking place in the RCF side of the facility and all activities took place in Assisted Living. Throughout the survey residents were observed remaining in their rooms or sitting at tables in the common area of the RCF. The need to ensure a daily activity program was provided for residents was reviewed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 06/05/24 at 3:00 pm. They acknowledged the findings.

1) A daily program of social and recreational activities in accordance with OAR 411-054-0030 will be conducted in the RCF. A separate monthly activity calendar will be created and posted for the RCF. 2) Daily activities that encompass group and individual interests and physical, mental and psychosocial needs will be provided for RCF residents. 3) The area needing correction will be evauluated weekly until completion and then monthly to ensure ongoing compliance. 4) The ED and Activity Director will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation addressed all required elements for 1 of 1 sample resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in May 2024 with diagnoses including diabetes, chronic pain disorder, and failure to thrive. Resident 1's move-in evaluation documentation was reviewed on 06/05/24. The following required elements were not addressed: * Effective non-drug interventions for mental health issues; * Personality: including how the person copes with change or challenging situations; * Housework and laundry; * Fluid preferences; * Fall risk or history; * Emergency evacuation ability; * History of dehydration or unexplained weight loss; * Unsuccessful prior placements; * Elopement risk or history; * Smoking; and * Environmental factors that impact the resident's behavior including, but not limited to, noise, lighting, and room temperature. In an interview on 06/06/24, Staff 1 (ED), acknowledged the Evaluation Form had multiple areas that were not completed. The need to ensure initial evaluations included all the required elements was discussed with Staff 1 on 06/06/24. She acknowledged the findings.

1) Resident #1 Evaluation and Service Plan will be updated to reflect all areas identified: non-drug interventions, Personality, Housework, Fluid preferences, Fall risk/history, Emergency evacuation ability, history of dehydration/weightloss, Unsuccessful prior placements, Elopement risk, Smoking and Environmental factors impacting behaviors. 2) Person that completed Evaluation and Service Plan for resident #1 was released from the community. New RCC completed Oregon Care Partners and Relias training including: The Role of Service Plans and Service Plans for Assisted Living Facilities. RCC also reviewed OAR 411-054-0034 (1-6). A signed aknowledgement of understanding is in the RCC's employment file. 3) The area needing correction will be evaluated weekly until completion and then quarterly. It will be completed with all new move ins. 4) It is the responsibility of the RCC and ED to ensure the corrections are completed and monitored.

2. Resident 2 was admitted to the facility in 02/2024 with diagnoses including arthritis and anxiety. Interviews with Resident 2 and care staff, and observations made of the resident during the survey revealed s/he was independent in all of his/her ADL's. Resident 2's current service plan, dated 05/16/24 was not reflective of the resident's current status in the following areas: * Interests, hobbies, social, leisure activities. The need to ensure service plans were reflective of the resident's current status was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 06/05/24 at 3:00 pm. The findings were acknowledged.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and/or provided clear direction to staff for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to: 1. Resident 1 moved into the facility in 05/2024 with diagnoses including diabetes, chronic pain disorder, and failure to thrive. The resident's current service plan dated 05/08/24 was reviewed, observations were made, and interviews with staff were conducted. Resident 1's service plan was not reflective and/or did not provide clear direction to staff in the following areas: * Wheelchair use; * Interests, hobbies, social, leisure activities; * Assistance required with ramp; and * Inability to chew hard foods. The need to ensure service plans reflected the residents' needs and provided clear direction to staff was discussed with Staff 1 (ED) on 06/06/24. She acknowledged the findings.

1) Resident #1 Service Plan will be updated to reflect clear direction to staff on Wheelchair use, Interests, hobbies and activities, Assistance required with ramp and Inability to chew hard foods. Resident #2 service plan will be updated to reflect Interests, hobbies and activities. 2) Person that completed Service Plan for resident #1 and #2 was released from the community. New RCC completed Oregon Care Partners and Relias training including: The Role of Service Plans and Service Plans for Assisted Living Facilities. RCC also reviewed OAR 411-054-0034 (1-6). A signed aknowledgement of understanding is in the RCC's employment file. 3) The area needing correction will be evaluated weekly until completion and then quarterly. It will be completed with all new move ins. 4) It is the responsibility of the RCC and ED to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#3) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: Resident 3 was admitted to the facility in April 2024 with diagnoses including diabetes. The resident required sliding scale insulin injections once daily by unlicensed staff. Review of the current delegation records for Resident 3 on 06/05/24 revealed there was no documented evidence Staff 9, Staff 12 and Staff 14 (MT's) had current evaluation of skills to determine continued competency for insulin administration. Witness 1 (CoBridge RN Consultant) reported that all required re-evaluation of delegations would be completed by end of day 06/05/24 and that only current delegated staff would administer insulin to the resident. On 06/05/24, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED) and Staff 3 (Health Services Director). They acknowledged the findings.

1) MT's 9, 12 and 14 received re-evaluation of delegations under OAR 411-054-0045. Only appropriately delegated and supervised staff in accordance with OSBN Administrative rules OAR 411-054-0045 will administer insulin to a resident. 2) Unlicensed staff (MT's) will have documented evidence of current evaluations of skills to determine competency for insulin administration. Only current RN -delegated staff will administer insulin to residents. 3) The area needing correction will be evaluated weekly until completion and monthly thereafter. 4) It is the responsibility of the RN, RCC and ED to ensure corrections are completed and monitored.

Based on interview and record review it was determined the facility failed to ensure an Acuity Based Staffing Tool (ABST) included evaluated care needs of all residents, and was completed for each resident before move-in. Findings include, but are not limited to: The ABST was reviewed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 06/04/24, and the following was identified: The ABST did not include two residents. In an interview on 06/04/24, Staff 1 reported that a resident who moved into the facility on 06/03/24 did not have a completed ABST. Staff 2 reported that another resident was erroneously omitted from the ABST and included in the ABST for the assisted living facility. The need to implement an ABST based on the evaluated care needs of all residents, including completing an ABST assessment before a resident move-in, was discussed with Staff 1 (ED) on 06/06/24. She acknowledged the findings.

) The ABST was reviewed for accuracy and updated to reflect the current population in the ALF as well as the RCF. ABST will be compared to the resident roster and monitored for accuracy. 2) Resident ABST assessments will be updated at least quarterly and reviewed for accuracy to reflect the amount of staff needed to meet the 24-hour scheduled and unscheduled needs of the residents. 3) The area needing correction will be evaluated/updated weekly until completion and then monthly and/or as often as needed. 4) It is the responsibility of the RCC, RCF Administrator and ED to ensure corrections and updates are completed and updated.

Based on interview and record review, it was determined the facility failed to implement a proprietary acuity-based staffing tool (ABST) that was Department-approved. This is a repeat citation. Findings include, but are not limited to: On 11/19/24 at 10:00 am, the facility's propriety ABST was reviewed with Staff 1 (ED) and Staff 6 (RCF Director). There was no documented evidence the Department had approved the facility's proprietary tool. No additional information was provided. The need to ensure the facility implemented a Department-approved ABST was discussed with Staff 1 and Staff 6 on 11/20/24. They acknowledged the findings.

1. All residents have been transferred over to the ODHS Acuity Based Staffing Tool as of 12/03/2024. 2. New residents that move in will be added to the ODHS ABST. Resident assessments will be updated at least quarterly or upon a change of condition and the ABST will be reviewed for accuracy to reflect the amount of staff needed to meet the 24-hour scheduled and unscheduled needsof the residents. 3. The area needing correction has been transferred over to the ODHS ABST and will be monitored as often as needed based off of resident assessments, changes of conditions and needs. 4. It is the responsibility of the RCC, RCF Administrator and the ED to ensure the corrections and updates are completed and updated.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 9 and 10) completed all required pre-service orientation training, and 1 of 3 newly hired direct-care staff (#10) completed all required pre-service dementia training. Findings include, but are not limited to: Staff training records reviewed on 06/04/24 at 8:30 am with Staff 4 (Business Office Manager) identified the following: 1. There was no documented evidence Staff 10 (CG), hired on 04/23/24 had completed the following required pre-service orientation topics: * Resident rights and values of CBC care; * Abuse reporting requirements; and * Approved HCBS course (effective 04/01/24). 2. Staff 9 (CG) lacked documented evidence of completing the following pre-service orientation topic: * Approved HCBS course (effective 04/01/24). 3. Staff 10, hired on 04/23/24, lacked documented evidence of required pre-service dementia training on the following topics: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Strategies for addressing social needs & engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities was discussed with Staff 4 (Business Office Manager) on 06/04/24 at 3:45 pm and Staff 1 (ED) and Staff 2 (VP of Operations) on 06/05/24 at 3:00 pm. The findings were acknowledged.

1) Newly hired team members 9 and 10 not currently in compliance with pre-service orientation trainings including Residen Rights, Abuse reporting, and the approved HCBS course will be removed from the schedule pending completion of the trainings. Training for team member 10 will also include pre-service dementia training. 2) Newly hired team members will not be on the scheduled to provide care to residents until all required pre-service trainings identified in OAR 411-054-0070 are completed as well as any required certifications and licenses pertaining to specific job descriptions and positions.. 3) This area will be evaluated weekly until completion and then on an ongoing basis, every time a new team member is hired. 4) It will be the responsibility of the BOM, Staff Scheduler and ED to ensure that corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct-care staff (#s 8, 9, and 10) demonstrated satisfactory performance in all assigned duties within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 06/04/24. The following deficiencies were identified: Staff 8 (CG), hired 02/12/24, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire: * Changes associated with normal aging; and * First Aid/abdominal thrust. Staff 9 (CG), hired 03/26/24, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire: * First Aid/abdominal thrust. Staff 10 (CG), hired 03/26/24, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire: * Changes associated with normal aging; * General food safety, serving and sanitation; and * First Aid/abdominal thrust. The need to ensure newly hired direct-care staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 4 (Business Office Manager) on 06/04/24 at 3:45 pm and Staff 1 (ED) and Staff 2 (Vice President of Operations) on 06/05/24 at 3:00 pm. They acknowledged the findings.

1) Newly hired team members 8, 9 and 10 not currently in compliance with documented evidence of demonstrated satisfactory performance within 30 days of hire in First Aid/Abdominal Thrust training, Changes associated with normal aging and General Food Safety will be removed from the schedule pending completion of the trainings. 2) Newly hired team members will not be on the schedule to provide care to residents until all required pre-service trainings identified in OAR 411-054-0070 are completed as well as any required certifications and licenses pertaining to specific job descriptions and positions. BOM and Staff Scheduler will monitor new hires to ensure trainings within 30 days of hire are completed timely. 3) This area will be evaluated weekly until completion and then on an ongoing basis, every time a new team member is hired. 4) It will be the responsibility of the BOM, Staff Scheduler and ED to ensure that corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to consistently provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: The facility provided documentation of fire and life safety training for staff conducted on 05/25/24. No other documentation was provided. In an interview with Staff 5 (Environmental Services Director) on 06/04/24, he reported that no fire drills had been conducted in the past three months since the facility had been reopened after a remodel. Staff 5 also reported he was unaware that he needed to conduct fire drills and staff fire and life safety training separate from the rest of the building which was a separate license. The need to conduct fire drills every other month and provide fire and life safety instruction to staff on alternate months for each licensed facility was discussed with Staff 5 on 06/04/24 and Staff 1 (ED) on 06/06/24. They acknowledged the findings.

1) An annual calendar with scheduled unannounced fire drills and life safety trainings has been implemented. Fire drills in the RCF will be conducted separately from the ALF 2) Education will be provided to and reviewed with the ESD utilizing OAR 411-054-0090. Documented evidence of the fire drills will be kept. Inservice logs and training content outlines will be placed in a binder. 3) Fire Drills and Life Safety trainings will be evaluated monthly to ensure it is in compliance with OAR's. 4) The ESD and ED are responsible to ensure that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to have a system for instructing residents within 24 hours of admission and re-instructing them, at least annually, in fire safety topics. Findings include, but are not limited to: In an interview on 06/05/24, Staff 5 (Environmental Services Director) reported he had not yet provided the required instruction on fire safety procedures and evacuation methods to Resident 1, who moved into the facility on 05/08/24. He stated he was developing a system to instruct residents within 24 hours of move in and re-instructing them at least annually. The need to ensure residents received fire safety instruction within 24 hours of move-in, and were re-instructed annually, was reviewed with Staff 1 (ED) and Staff 5 on 06/05/24. They acknowledged the findings.

1) ESD is developing a system to track and document new move-ins to ensure that all new move-ins are instructed within 24 hours of move in on fire safety procedures and evacuation methods and again re-instructing at least annually, per OFC. 2) A tracking system will be utilized by the ESD to ensure all new move ins are instructed within 24 hours of move in and re-instructed annually the facility's general fire and life safety procedures and evacuation methods. Written record of fire safety trainng including content of the training as well as residents attending will be kept. 3) For current residents, this area of correction will be evaluated weekly until completion and bi-annual for annual re-instruction. For new move-in's, this area needing correction will be evaluated at the time of each move-in. 4) It will be the responsibility of the ESD and ED to ensure these corrections are completed and monitored.

Based on observation and record review, it was determined the facility failed to ensure the grounds were orderly and free of litter and refuse, garbage was stored in covered refuse containers, cleaning chemicals and disinfectants were secured in locked storage, and measures were taken to prevent the entry of rodents, flies, mosquitoes, and other insects. Findings include, but are not limited to: The facility grounds and interior of the Residential Care Facility (RCF), comprised of units Diamond and Willow, were toured on 06/03/24 and 06/04/24, resident council notes were reviewed, and observations were made throughout the survey. No resident units in Willow were occupied, but doors between the units were open and residents from Diamond were occasionally observed in Willow. The following was identified: * Broken furniture and other refuse were stacked in a pile behind the designated smoking area for staff and was observable from the pathway used by residents. * Multiple cigarette butts were on the ground to the right of the front entrance. * Piles of bird droppings were on the walkway at either side of the front entrance. * The inner courtyard of Diamond contained window screens and large pieces of peeled paint on the ground. * The pathway in the inner courtyard of Diamond was uneven and had drop-offs. * A large painted planter box in the outer courtyard of Willow had large areas of peeling paint, with exposed and splintered wood. There was lumber stacked underneath the planter box. * A bottle of disinfectant was in an unlocked eyewash station of Diamond. * Cleaning chemicals were stored in an unlocked room next to the rear corridor connecting Diamond and Willow. * Two resident room window screens, observed from the inner courtyard of Diamond, had large holes, approximately 3" in diameter, allowing insects to enter the building. * Throughout the survey a door to the outer courtyard on Diamond was intermittently observed propped open, allowing insects to enter the building. * Ants were observed on the floor in the Willow common area, as well as in the bathroom by the Willow kitchenette. * On 06/04/24 flies were observed in an uncovered garbage dumpster, the lid of which was pinned behind the dumpster and the fence. On 06/05/24 this was shown to Staff 5 (Environmental Services Director), who covered the garbage dumpster. The morning of 06/06/24 the dumpster was observed to be uncovered. * Resident Council notes dated 05/20/24 had the following comments from two unsampled residents:  - "Can the bug situation in RCF be addressed. Large bugs in there!"  - "Air doors to get flies out of dining area. Ongoing problem!" The findings were reviewed in a tour of the facility on 06/05/24 with Staff 1 (ED) and Staff 5. They acknowledged the findings.

1) Broken furniture and refuse will be disposed of.The pillars at front entrance have been power washed to remove the bird excrement. Bird nests have been removed and spikes will be placed in the areas of where the bird nests were located. Discarded cigarettes have been removed. Inner courtyard will be cleaned. ESD will work on getting bids to have the uneven pathway with drop offs fixed. Planter box and lumber in outer courtyard will be disposed of. All chemicals/disinfectants will be removed from common areas and stored out of reach of residents. Window screens with holes will be fixed/replaced. Residents are being reminded to not prop exterior doors open and items to prop the doors open have been removed. Ecolab has been in the community to spray for ants. All staff members have been instructed to cover/close dumpsters after throwing garbage away. 2) Broken furniture will be replaced. Spikes will be placed at the top of the pillars to prevent birds from perching and nesting on the pillars. Residents that smoke are being reminded of the smoking areas and to use proper disposal recepticles for their cigarettes. Housekeepers will monitor the area twice a day for discarded cigarettes. Interior courtyards and exterior areas accessible to residents will be cleaned and hazardous items/items in disrepair will be discarded. Items being used to prop open exterior doors have been removed. Pest service has been initiated for pest control. Team members have been instructed to keep dumpsters closed and this will be reviewed at monthly All-Staff meetings. 3) These areas needing correction will be monitored and evaluated weekly until completion and then on a monthly basis. Doors propped open, dumpsters left open and cleaning chemicals/disinfectants left out will be monitored daily. 4) The ESD as well as ED are responsible to ensure that the corrections are completed and monitored for compliance.

Based on observation and record review, it was determined the facility failed to ensure facility exterior pathways were in good repair and free from drop-offs and uneven surfaces. This is a repeat citation. Findings include, but are not limited to: The facility grounds were toured on 11/18/24 and 11/19/24 and showed the following: * Multiple exterior pathways, as well as interior courtyard pathways, were observed. The pathways were found to have large cracks in sections of the sidewalk in addition to raised edges and drop-offs between surfaces of several inches. The uneven surfaces created potential tripping hazards. * Drop-offs at the pathway edges were from two to six inches in height. The most significant drop-offs were noted at the edges of ramps in the center courtyard between the two sides of the building. The findings were discussed with and/or shown to Staff 1 (ED) and Staff 6 (RCF Director) on 11/19/24. They acknowledged the findings.

1. A bid has been accepted for the repair of exterior pathways, courtyards and parking lot. Work will be completed in the spring, when weather allows. Extension for work to be completed in the Spring was granted by Anne Bardana,CBC Survey Manager on 12/4/2024 2. Sections of broken concrete will be removed and replaced. Sections of asphalt in parking lot will also be removed/repaired and leveled with concrete areas. 3. Areas needing correction will be monitored and evaluated on a monthly basis. 4. The ESD, ED and Assistant ED are responsible to ensure that the corrections are completed in the spring and monitored for compliance.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to: A tour of the Residential Care Facility (RCF) interior, comprised of units Diamond and Willow, was conducted on 06/03/24. The following were found to need cleaning and/or repair: * Dining chairs in both units had scrapes and gouges in the wood. * Dining tables in both units had black build-up on wood surfaces. * Acoustic ceiling tile in the short corridor by the Diamond medication room had a large brown stain, approximately 18" in diameter, and the ceiling tile next to it was missing. * Moss was growing on the inside of the windows facing the Willow inner courtyard, and window tracks had brown build-up. On 06/05/24 these findings were reviewed on a walk-through of the RCF with Staff 1 (ED) and Staff 5 (Environmental Services Director). They acknowledged the findings.

1)Damaged dining chairs and tables will be removed and discarded if they cannot be repaired and or cleaned. New furniture is expected to be ordered in the near future. Stained and missing ceiling tiles will be replaced. Moss growing on the inside of the windows and the brown build up in the tracks will be removed and window tracks will be sanitized. 2) The community is scheduled to receive new furniture including dining tables and chairs. Any and all ceiling tiles that are missing or dirty will be replaced. Windows that have moss and or build-up in the tracks will be inspected for leaks and repaired as necessary. 3) This area will be evaluated weekly until completion and then quarterly thereafter. It will be the responsibility of the ESD and the ED to ensure corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure residents' rooms had a lockable storage space for the safekeeping of residents' small valuable items and funds. Findings include, but are not limited to: Interviews with Resident 1 on 06/03/24 and Resident 2 on 06/04/24 identified that resident closets had a locking mechanism but residents were not given keys. There were no other lockable storage spaces in the residents' rooms. The need to ensure resident rooms had a lockable storage space was discussed with Staff 1 (ED) on 06/06/24. She acknowledged the findings.

1) All locking mechanisms on resident storage closets will be inspected for functionality. Any locks that do not function properly will be repaired and/or replaced. ESD will ensure that all RCF residents have a key to the locking closet in their room. 2) Any broken or missing locks will be repaired/replaced. Residents that do not currently have a key to their locking storage will receive a key. 3) This area of correction will be evaluated weekly until completion and then as needed. 4) It will be the responsibility of the ESD and ED to see that the corrections are completed and monitored.

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 installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to: On 06/03/24 a gas fireplace was observed in the common sitting area between units Willow and Diamond. The fireplace was located where residents could come into incidental contact with it. The fireplace glass measured 235.0 degrees F when measured with the surveyor's thermometer. On 06/04/24 Staff 1 (ED) and Staff 5 (Environmental Services Director) acknowledged the surface temperature was too hot and immediately disabled the fireplace until a long term solution could be found.

1) Gas fireplace is currently disabled. ESD has been in communication with Orely's in Klamath Falls for a solution so that fireplace can operate withing the guidelines of OAR 411-054-0200 (8). If a solution cannot be found, fireplace could possibly be replaced with an electric fireplace. 2) Fireplace will remain disabled until a permanent solution if found. 3) This area needing correction will be evaluated weekly until completion and monthly thereafter/ 4) It will be the responsibility of the ESD and ED to see that corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system for security purposes to alert staff when residents exited the (Residential Care Facility) RCF. Findings include, but are not limited to: The interior of the RCF, comprised of units Diamond and Willow, was toured on 06/03/24 and 06/04/24. Diamond and Willow each had two double doors through which residents could exit the building into exterior courtyards. In addition, each unit had two doors through which residents could exit the building into interior courtyards. When the surveyor exited the building through these eight doors, no audible alert was heard. In an interview on 06/05/24, Staff 5 (Environmental Services Director) confirmed that there was not a system in place that alerted staff when residents exited the building through these eight doors. Staff 5 reported that the four double doors had alarms which had been disabled when crash bars were installed. These findings were reviewed with Staff 1 (ED) during a walk-through of the environment on 06/05/24. She acknowledged the findings.

1) ESD will install audible alarms on the 8 exterior doors identified. 2) RCF staff will be trained on OAR 411-054-0200 Exit Door Alarms and the purpose of the alarms. 3) This area will be evaluated daily until correction and then monthly thereafter. 4) It is the responsibility of the ESD and Ed to ensure that the corrections are made and monitored.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance: Integrated Settings: Community Life OAR 411-004-0020 (1)(a) The setting is integrated in and supports the same degree of access to the greater community as people not receiving HCBS, including opportunities for individuals enrolled in or utilizing HCBS to: (B) Engage in greater community life.

During the survey concerns were identified in the following area and the facility was provided with technical assistance: Optimize Settings: Independence Activities OAR 411-004-0020 (1)(e) The setting optimizes, but does not regiment, individual initiative, autonomy, self-direction, and independence in making life choices including, but not limited to: daily activities, physical environment, and with whom the individual chooses to interact.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance: Physical Setting Individual Accessible: OAR 411-004-0020 (2)(b) Provider owned, controlled, or operated residential settings must have all of the following qualities: The setting is physically accessible to an individual.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance: OAR 411-004-0020(2)(d): Individual Privacy: Own Unit (d) Each individual has privacy in his or her own unit. This was regarding no lock on the apartment side of the door to shared bathrooms.

Based on interview and record review, it was determined the facility failed to ensure their proprietary acuity-based staffing tool (ABST) used established care time that was resident-specific, rather than a pre-determined average, and that developed a staffing plan for each shift that met the scheduled and unscheduled needs of all residents. Findings include, but are not limited to: On 11/19/24 at 10:00 am, the facility's proprietary ABST was reviewed with Staff 1 (ED) and Staff 6 (RCF Director). They were unable to explain if the 22 ADLs in the ABST were represented as minutes or as points or how their ABST accounted for both scheduled and unscheduled needs of residents. The need to ensure the ABST used by the facility used resident-specific care time rather than a pre-determined average, and developed a staffing plan for each shift that met the scheduled and unscheduled needs of all residents was discussed with Staff 1 and Staff 6 on 11/20/24. They acknowledged the findings.

1. All residents have been transferred over to the ODHS Acuity Based Staffing Tool as of 12/03/2024. 2. New residents that move in will be added to the ODHS ABST. Resident assessments will be updated at least quarterly or upon a change of condition and the ABST will be reviewed for accuracy to reflect the amount of staff needed to meet the 24-hour scheduled and unscheduled needsof the residents. 3. The area needing correction has been transferred over to the ODHS ABST and will be monitored as often as needed based off of resident assessments, changes of conditions and needs. 4. It is the responsibility of the RCC, RCF Administrator and the ED to ensure the corrections and updates are completed and updated.

Based on 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 C361 and C510.

1. POC for C361 has been implemented and completed. The community is now using the ODHS ABST. POC for C510 has been granted an extension by Anne Bardana, CBC Survey Manager on 12/04/2024. The work for C510 will need to be completed under the right weather conditions and therefore will need to wait until the spring for completion. 2. System for C361 has been corrected by the utilization of the ODHS ABST. System for C510 will be corrected in the spring 2025 by replacing broken cement walkways and the repairs of the asphalt parking lot. 3. C361will be monitored on an ongoing and as needed basis. C510 will be monitored until completion which is expected to be in the Spring of 2025. 4. RCC, Assistant ED and Executive Director will be responsible to see that C361 is monitored. ED, Assistant ED and ESD will see that C510 is completed and monitored.

The findings of the 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 and OARs 411 Division 004 Home and Community Based Services Regulations. 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 change of ownership survey of 06/06/24, conducted 11/18/24 through 11/20/24, 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 and OARs 411 Division 005 for Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Resident Care and Assisted Living Facilities rules. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day