Brookdale Forest Grove

C240:

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 08/27/25 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas:

* Dishwashing area – caulking and wall above back splash – build up of black matter, walls below dirty side of dishwasher drips of brown/black matter, shelf holding dish racks with dried white matter;

* Floor and drain between steamer and flat top grill – food debris/build up of black matter;

* Wall behind flat top grill and stove – grease drips;

* Top of partial wall behind cooking equipment – dusty/greasy;

* Interior of drawer next to stove – loose debris/food particles;

* Oven doors and knobs – drips/spills/dried debris;

* Commercial can opener – blade finish worn/black matter build up on housing of opener;

* Four burner stove – doors with spills/knobs with dried debris/crusty build up;

* Upper and lower shelves throughout the kitchen – spills/debris/dried food;

* Walk in refrigerator fan cover – dusty;

* Convection oven – sides/front drips/grease, top dusty;

* Lids on food bins – food debris;

* Stand mixer shelves – debris/spills/dusty;

* Ecolab MSDS notebook on wall next to stand mixer – dusty;

* Stainless steel doors on service line – smears/spills;

* Exterior of garbage cans – food drips/spills;

* Wall behind ice maker and vents – heavy build up of dust;

* Wall above and behind refrigerator near service line – dust build up;

* Single door refrigerator near service line – exterior door with smears/drips/spills; and

* Three door freezers – bottom shelves with debris/spills, exterior doors with smears/drips/spills, vents above and below doors dusty.

Improper food storage included:

* Bags of croutons – not dated/labeled;

* Multiple open bags of food in refrigerators – not dated/labeled and/or securely closed (bacon, green beans, salad, raw chicken, shredded cheese);

* Uncovered container of cornmeal;

* Bin with granulated sugar open to air;

* Dry storage – boxes sitting directly on floor;

* Bags of open frozen foods not securely closed and/or not dated/labeled;

* Shelled eggs stored above containers of ready to eat food in refrigerator near service line; and

* Walk in refrigerator speed rack – trays of uncovered food items.

Other areas of concern:

* Colored cutting boards – finish worn and scored;

* Ceiling lights above food bins and in dry food storage were uncovered.

The areas of concern were observed and discussed with Staff 1 (Lead Cook) on 08/27/25. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 09/04/24 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas:

* Microwave oven – interior food splatters;

* Hood vents on both sides above stoves/grill – buildup of dust and grease;

* Shelves below steamer and one sink counter – drips/splashes/debris;

* Front and sides of stoves and oven doors – drips/spills;

* Convection oven – sides/top/doors/legs had spills/drips/debris;

* Pipes between stove and steamer – significant buildup of black matter;

* Wall behind stove across from steam table – grease/drip buildup;

* Back of grill top – significant buildup of grease/food splatter;

* Front of stainless-steel doors on the steam table – drips/spills/smears;

* Commercial mixer – food splatter on base behind the bowl;

* Food bins lids on oatmeal and flour – food debris ;

* Floor under and behind stove (across from steam table) – buildup of black matter;

* Floor under two sink counter – buildup of black matter near the wall and drain had significant buildup of black/brown matter;

* Upright refrigerator and freezers – bottom shelves had buildup of food debris/spills;

* Ice machine – buildup of dust on intake vent: and

* Dishwashing machine – top had buildup of dried debris.

The following concerns relate to improper food storage:

* Upright refrigerator and walk in refrigerator – contained unlabeled/undated food items;

* Upright refrigerator – eggs (in shells) not stored on lowest shelf, creating possible cross contamination if cracked; and

* Food bins containing bags of brown and granulated sugar had lid missing, bags were open to the air, creating possible cross contamination.

The areas of concern were observed and discussed with Staff 1 (Lead Cook/PIC) and discussed with Staff 2 (Executive Director) on 09/04/24. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

The findings of the re-licensure survey conducted 03/21/23 through 03/24/23 are documented in this report. The survey was conducted to determine compliance with the OAR 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OAR 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit to the re-licensure survey of 03/24/23, conducted 09/19/23 through 09/20/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second revisit to the re-licensure survey of 03/24/23, conducted 12/06/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the third re-visit to the re-licensure survey of 03/24/23, conducted 03/24/25, 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 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 provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:During the relicensure survey, conducted 03/21/23 through 03/24/23, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.Refer to deficiencies in the report.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:A review of Resident Council Board Meeting minutes dated 01/08/23, 01/11/23, 02/05/23, and 03/05/23 identified the following resident concerns:* "Residents have been having wrong medication at wrong time or wrong medication altogether";* "Out of Meds - still not ordering meds on time and running out for up to 48 hours";* "Care givers have been seen running meds to the residents for the Med Techs";* "Many residents have never seen their care plan and do not know what it is"; and* "Sometimes don't see a care giver for days and don't know who they are".There was no documented evidence the above concerns identified during the Resident Council board meetings had been addressed, responded to or resolved. On 03/21/23, the survey team conducted a group interview with residents. They expressed complaints about cleanliness of the facility, food quality and service, dissatisfaction with caregiving, untimely medication administration, lack of resolution for concerns from resident council meetings, and fear of retaliation from administration if concerns were brought forward. In an interview on 03/23/23, Staff 1 (District Director of Operations) reported residents may make an entry in the facility's "Grievance Log" located at the reception desk when they had concerns. Staff 1 indicated the facility was "addressing" the items in the log; however, no documented evidence existed indicating any items had been resolved. The need to improve the facility's method for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 2 (District Director of Clinical) on 03/24/23 at 11:35 am. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to assure appropriate responses to incidents of suspected abuse and elopement were investigated and reported to the local SPD office or the local AAA office for 2 of 2 sampled residents (#s 1 and 2) with documented allegations of neglect of care or elopement. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 06/2022 with diagnoses including chronic pain and hypertension.Resident 1's service plan available at the time of the survey, dated 11/10/22, noted the resident was frequently incontinent of bowel and bladder, required assistance from two staff members for tasks that required standing/weight bearing, and received home health services for redness/excoriation on the buttocks.During an interview on 03/22/23 at 10:00 am, Witness 1 (outside provider) stated the resident received outside services for wound care three times a week. Review of outside service provider notes between 02/15/22 and 03/23/23 noted the following:* 02/15/23 "pt [patient] found in soiled brief";* 02/18/23 "pt [patient] very soiled - 100% saturated brief ....put light on for caregiver assistance ...no response from cg [caregiver] for over an hour ..."* 02/24/23 " ...pt [patient] had no drsg [dressing] in place ...make sure pt [patient] is changed every 2 hours ..."* 02/27/23 "pt [patient] found in 100% saturated 2 briefs, 3 chux [incontinent pads] and urine up [his/her] shirt ...wound dressing placed last Friday still in place with soiled urine/stool ..."Resident 1 received wound care on 03/23/23 at 9:25 am, the dressing was soiled and there was brown matter on the incontinent product. Staff 20 (MT) changed the resident's dressing and provided incontinent care.The statements documented by the outside service provider identified potential neglect of care. There was no documented evidence the facility investigated the allegations of neglect of care or reported the allegations to the local SPD or AAA office as suspected abuse.The lack of investigating and reporting was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/23/23 at 11:00 am. Staff acknowledged the statements should have been investigated. The various allegations pertaining to neglect of care were reported to the local SPD office during survey and verification was received on 03/24/23.
2. Resident 2 was admitted to the facility in 08/2019 with diagnoses including dementia.During the acuity interview on 03/21/23, the facility reported Resident 2 had a recent elopement incident and required an escort back to the facility.Resident 2's progress notes, dated 02/09/23 through 03/20/23, were reviewed and revealed the following documentation on 03/03/23, " ...resident was having wandering issues from the facility today."In an interview on 03/22/23 at 12:54 pm, Resident 2 reported approximately three weeks ago s/he walked to a local store alone and was unable to find his/her way back to the facility. A police officer then escorted the resident back to the community. On 03/23/23, Staff 4 (RN Oversite) and Staff 6 (Resident Services Coordinator) confirmed the resident's need for a police officer escort after getting lost in the community. Documentation of an investigation of the elopement event and/or referral to Seniors and People with Physical Disabilities (SPD) office was requested on 03/23/23. No documentation was provided.The need to promptly investigate and report all reportable incidents to the local SPD office was discussed with Staff 1 (District Director of Operations), and Staff 2 (District Director of Clinical) on 03/24/23. They acknowledged the findings. A report was filed with the local SPD office and documentation provided on 03/24/23 at 2:08 pm.
Based on interview and record review, it was determined the facility failed to report suspected abuse to the local Seniors and People with Disabilities (SPD) office and failed to have documented evidence of an administrator review of investigations, for 1 of 1 sampled resident (# 10) who was involved in resident to resident altercations. This is a repeat citation. Findings include, but are not limited to: Resident 10 was admitted to the facility in 04/2022 with diagnoses including dementia.Resident 10's current service plan, dated 06/25/23, progress notes dated 07/07 through 09/12/23, and interviews with care staff between 09/19 and 09/20/23 noted the resident had cognitive impairment, was combative towards staff at times surrounding ADL care, had a history of resident-to-resident altercations, and had been overheard yelling and screaming at spouse and other residents. a. An incident report dated 09/02/23 noted, "...yelling in dining room, no physical, but [resident] threatening to smack..." The residents were separated by staff and removed from the area.Threatening to hit constitutes verbal abuse and required reporting to the local SPD. There was no documented evidence the facility immediately reported the event to the SPD. Staff 34 (Health and Wellness Director III) reported the verbal abuse to SPD and confirmation of the report was provided prior to survey exit.b. Resident 10 was involved in three resident-to-resident altercations. The local SPD was notified, actions/interventions were identified and put into place, and investigations completed; however, there was no documented evidence the investigations were reviewed by the Administrator.The need to ensure verbal abuse was reported to SPD and investigations were reviewed by the Administrator was discussed with Staff 33 (Executive Director II), Staff 34, and Staff 2 (District Director of Clinical) on 09/20/23. Staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair, kitchen staff did not follow hygienic practices and proper food handling procedures in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 03/21/23 at 10:00 am, the main kitchen, walk-in refrigerator, two reach-in freezers, and dry food storage area were observed to need cleaning in the following areas:a. Kitchen area:* Walls throughout the kitchen had multiple spills, smears, splatters and black streaks;* Pipes behind multiple appliances had grease, dirt, and debris;* Cooktop knobs and handles had sticky matter, built-up grease and dried food debris;* Interior walls of ice-maker machine had unidentified black residue; * Air intake vents of ice-maker machine were covered with dust; * Drains beneath three-compartment sink and on the floor next to the oven were filled with food and other debris;* Floors throughout the kitchen had food debris and grease in the corners, under equipment and around the perimeter of the kitchen;* Ceiling vent above storage shelves across from walk-in refrigerator was covered with dust;* Cooktop backsplash panel was covered with burnt-on grease and other residue; * Range hood filters were covered with grease; * Glass shield in front of serving line chafing dishes were covered with food splatters; * Oven interior, knobs, doors and handles;* Microwave interior, doors and handles;* Air intake vent on front of toast machine was covered with dust and other matter; * Industrial mixer and scale; * Light fixture covers on ceiling in dry storage room had dead insects inside; * Open shelving throughout the kitchen; and* Electrical outlets. b. Walk-in refrigerator:* Refrigerator cooling unit fans had a layer of dust and dirt. Ceiling and walls of walk-in refrigerator had dust build up from fans; and * Light switch junction box covered with rust and dust. c. Reach-in freezers:* Bottom shelves with food debris; and* Exterior surfaces and handles covered with sticky residue. d. Dining room beverage area:* Juice and coffee machines observed with splatters and fluid build-up.On 03/21/23 at 10:00 am, the main kitchen was observed to need the following repairs:* Blade on can opener observed with protective coating removed from wear and rust developing; * Caulking around chafing trays was worn; * Dripping water visible and pooling of water observed under steamer; * Multiple cutting boards were found heavily scored and/or stained and in need of replacement;* Approximately two inch hole in wall surrounding sink drainage pipe next to cutting board rack; * Employee hand-washing station was not functioning; * Two light fixtures above service line area with burnt out bulbs and cracked fixture covers; * Unidentified electrical box next to dish racks were covered with dirty tape; * Water stains on ceiling above warewash machine; * Drywall surface peeling on ceiling above reach-in freezers; and * Industrial mixer was rusted in several places and not covered when not in use as required.On 03/21/23 at 11:30 am, the following improper food handling practices were observed:* Staff 19 (Cook) was observed using single-use gloves for multiple tasks, including food handling, cooking and operating appliances; kitchen staff was observed using sanitation rags to wipe gloved hands during meal service;* Individual portions of dessert were plated on trays in the walk-in refrigerator, left uncovered and open to direct dust and debris contamination from blowing fans;* Frozen condensation drops observed on top of rightmost reach-in freezer; and * Multiple food items in the walk-in refrigerator and reach-in freezers were found removed from their original packaging, not dated and only partially wrapped. Bulk food items were found not dated when opened.Four garbage cans throughout the kitchen were not covered with lids when not in use.Facility did not have a cleaning schedule in place. Staff 18 (Cook) stated the facility had developed a schedule for kitchen cleaning on 03/20/23 but had not implemented it yet. Staff 1 (District Director of Operations) stated the facility had placed a request for bids for deep cleaning of kitchen and ice-making machine, but nothing had been scheduled. Additionally, during a tour of the kitchen on 03/22/23 to share survey findings, Staff 19 was observed not wearing gloves when preparing food.The findings were discussed with Staff 1 and Staff 8 (Maintenance Supervisor) on 03/22/23 at 11:45 am. Both staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation was dated, contained all required elements and addressed sufficient information to develop an initial service plan to meet the resident's needs, for 1 of 1 sampled resident (# 5) who was recently admitted to the facility. Findings include, but are not limited to: Resident 5 was admitted to the facility in 01/2023 with diagnoses including hypertension, osteoarthritis, and depression. Review of the move-in evaluation revealed the evaluation was not dated and the following required elements were not documented as being addressed:* Customary routine related to eating;* Visits to health practitioners, ER, hospital, or nursing facility in the past year;* Vital signs if indicated by diagnosis, health problems or medications;* Presence of depression, thought disorders, behavioral and mood problems;* History of treatment;* Effective non-drug interventions;* Personality, including how the person copes with change or challenging situations;* Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort;* Nutritional habits and weight if indicated; and* Recent losses. The need to ensure the initial evaluation was dated, contained all required elements and addressed sufficient information to develop an initial service plan to meet the resident's needs was reviewed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23 at 11:35 am. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 06/2022 with diagnoses including chronic pain and hypertension.Observations and an interview with the resident, interviews with staff and a witness, and review of the resident's clinical record during the survey revealed s/he required staff assistance for ADL care needs. a. Resident 1's service plan available at the time of the survey, dated 11/10/22, was not reflective of or in the following areas: * Pain;* Barrier cream applied during ADL care;* Frequency of position changes;* Frequency of home health visits; and* Sleeping preferences.b. The service plan available at the time of the survey was dated 11/10/22 and had not been updated quarterly as required. The need to ensure the service plan was reflective of Resident 1's current needs and completed quarterly was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/23/22 at 11:00 am. The service plan was updated during the survey.
4. Resident 3 was admitted to the facility in 01/2022 with diagnoses including diabetes. a. There was no documented evidence the facility completed a quarterly service plan. The most recent service plan available to staff was completed 11/04/22. b. A Temporary Service Plan (TSP) dated 03/18/23 identified the resident had returned to the facility after a stay in a skilled nursing facility. The TSP directed staff to "Chart on all shifts."A review of the clinical record revealed staff had not consistently charted on all shifts as directed by the plan of care. The need to ensure service plans were updated quarterly and TSPs were implemented was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23. They acknowledged the findings.
3. Resident 2 was admitted to the facility in 08/2019 with diagnoses including dementia.The resident's current service plan, dated 01/15/23, was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 03/21/23 and 03/24/23. Resident 2's service plan was not reflective and/or did not provide clear instruction to staff in the following areas:* Assistance required during laundry tasks;* Incentive spirometer frequency;* Need for increased fluids following 03/09/23 hospitalization; and* Ambulation without adaptive equipment within the community.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 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23 at 12:07 pm. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear directions regarding the delivery of services, were not implemented, a copy of the service plan was offered to the resident, and service plans were completed following quarterly evaluations for 4 of 7 sampled residents (#s 1, 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 01/2023 with diagnoses including hypertension, osteoarthritis and depression. Interviews with the resident and staff, and review of the current service plan, dated 02/06/23, revealed Resident 5's service plan was not reflective of current needs and lacked clear instructions to staff for bathing/showering.During an interview on 03/22/23 Resident 5 stated s/he was not offered a copy of service plan. The need to ensure the service plan reflected residents' current needs, provided clear instructions to staff regarding delivery of services and a copy was offered to residents was reviewed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23 at 11:35 am. They acknowledged the findings.
2. Resident 10 was admitted to the facility in 04/2022 with diagnoses including dementia.The current service plan dated 06/25/23 noted the resident needed stand-by assistance with dressing, using the restroom, escorts to the dining room, and had a wound on his/her heel. The service plan also noted the resident refused care at times and had verbal altercations with other residents in public areas.Interviews with caregiving staff and a medication aide on 09/19/23 and 09/20/23 noted the following:*Resident 10 was often overheard yelling at his/her spouse;*Resistive to care and would cuss and yell at staff;*Would scream and fight with spouse;*There was no wound on the resident's heel;*When the yelling started, the spouses would be separated;*Resident 10 enjoyed sitting in the lobby area near the fire place;*Staff would re-approach the resident when resistant to care or ask for another staff member to assist;*Holding the resident's hand while explaining care;*Using a calm voice when offering assistance and when escalated; and*Changing physical location at the onset of yelling. Progress notes dated between 07/07/23 and 09/12/23 were reviewed and noted two resident to resident altercations. One altercation was physical and the other was verbal. Both incidents occurred between the spouses.Resident 10 was observed during the survey to self propel him/herself to the dining room and the lobby area near the fire place or residing in the apartment. There was no yelling or screaming overheard between the spouses. Resident 10 had a history of resident-to-resident altercations, was overheard yelling and screaming at spouse, and was resistant to care. The current service plan was not reflective of the resident's status and did not provide clear instruction to staff related to intervening or de-escalating tense situations.The service plan was discussed with Staff 34 (Health and Wellness Director III), Staff 33 (Executive Director II), and Staff 2 (District Director of Clinical) on 09/20/23 at 11:03 am. Staff 34 updated the resident's service plan.

3. Resident 8 moved into the facility in 11/2020 with diagnoses including congestive heart failure and type II diabetes. Observations and interviews with the resident, staff interviews and review of the service plan dated 07/03/23 showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Use of a ROHO cushion (to decrease the amount of pressure on the sitting area) while in a wheelchair; and* Behaviors including inappropriate comments.The need to ensure Resident 8's service plan was reflective of current care needs and provided clear direction to staff was discussed with Staff 33 (ED) on 09/20/23 at 10:50 am. Staff reviewed the service plan and acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 3 of 4 sampled residents (#s 8, 10 and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 12 was admitted to the facility in 08/2021 with diagnoses including cerebral palsy, spinal stenosis, asthma, and dysphagia.Observations were made of the resident's care on 09/20/23. Interviews with facility staff and the resident were conducted. The current service plan dated 08/09/23 was reviewed. Resident 12's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:* Nutrition habits, fluid preferences and diet texture;* Instructions for aspiration precautions and interventions while choking; and* Electric mobility equipment precautions and instructions for proper maintenance.The need to ensure the service plan reflected the resident's current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 2 (District Director of Clinical), Staff 33 (Executive Director II), and Staff 34 (Health and Wellness Director III) on 09/20/23 at 2:40 pm. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident, for 3 of 7 sampled residents (#s 1, 2 and 5) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2 and 5's most recent service plans lacked documentation 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 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/23/23 and 03/24/23. Staff acknowledged the findings.

2. Resident 1 was admitted to the facility in 06/2022 with diagnoses including chronic pain and hypertension.Resident 1's service plan available at the time of the survey, dated 11/10/22, noted the resident was frequently incontinent of bowel and bladder, required assistance from two staff members for tasks that required standing/weight bearing, received home health services for redness/excoriation on the buttocks, and required both frequent position changes and brief changes.Resident 1's progress notes, skin management and open area flowsheets for 12/16/22 through 03/09/23 were reviewed and noted the resident was being monitored related to a pressure injury on his/her left buttock.There was no documented evidence the resident's skin was monitored consistent with evaluated needs after 03/09/23.Resident 1 was observed during the survey between 03/21/22 and 03/23/23 to be seated in various positions in a recliner chair. Resident 1 was observed to stand for wound care treatment, had a catheter, and was able to re-position in the chair multiple times during observations and interviews.The surveyor requested Staff 4 (RN Oversite) to provide an update regarding Resident 1's skin. On 03/24/23 Staff 4 noted, resident with pressure wound "...left buttock...followed by HH...there is noticeable improvement in the wound as there is no depth to the wound and granulation has taken place to surrounding areas..."Resident 1 was noted to have a change of condition related to skin breakdown, was dependent on staff for ADL care and received HH for wound care. There was no documented evidence the resident's skin was monitored weekly between 03/09/23 and the time of the survey 03/21/23. Monitoring changes of condition weekly through resolution was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/23/23 at 11:00 am. Staff acknowledged the finding and evaluated Resident 1's skin on 03/24/23.
3. Resident 3 was admitted to the facility in 01/2022 with diagnoses including diabetes and anxiety disorder. Resident 3's records were reviewed during the survey and revealed the following:On 02/26/23, Resident 3 had a fall and was sent out to the hospital where s/he was diagnosed with a left hip fracture and admitted to a skilled nursing facility.Resident 3 was readmitted to the facility from the skilled nursing facility on 03/18/23 after rehabilitation related to the hip fracture. There was no documented evidence that upon the resident's return, the facility evaluated the resident for a change of condition, monitored the resident, or referred to the RN to determine if further actions or interventions were needed. The need to ensure residents were evaluated, monitored and referred to the RN for changes of condition upon return to the facility was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23. They acknowledged the findings.
5. Resident 7 was admitted to the facility in 02/2022 with diagnoses including dementia and hypertension.The resident's progress notes, dated from 12/29/22 through 02/07/23, service plan, Temporary Service Plans and outside provider notes were reviewed. Resident 7's Power of Attorney (POA) and facility staff were interviewed. The following changes of condition were identified:a. On 01/16/23, staff reported in a progress note the resident "wasn't feeling well" and had a blood pressure of "153 over 101." Staff called the facility RN who advised them to have the resident lay down and "continue to monitor [his/her] blood pressure."There was no documented evidence the facility communicated the interventions to staff on each shift or monitored Resident 7 through resolution.b. On 02/03/23, a Nurse Practitioner went to the facility to "follow up on a fall." Documentation of the resident's outside provider note revealed, "Patient was in the parking lot of a store and tripped." The store called 911 and after the Emergency Medical Team evaluated Resident 7, they "let [him/her] go home."An interview with the resident's POA on 03/22/23 at 2:11 pm confirmed the incident.There was no documented evidence the facility determined and documented what action or intervention was needed for the resident, communicated the action or intervention to staff on each shift or monitored the resident through resolution. The need to ensure the monitoring of short-term changes of condition included determining and documenting what action or intervention was needed for the resident, communicating the determined action or intervention to staff on each shift, and documenting at least weekly until the condition resolved was reviewed with Staff 1 (District Director of Operations), Staff 2 (District Director of Clinical) and Staff 4 (RN Oversite) on 03/24/23. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and communicated to staff, and the condition was monitored, at least weekly, through resolution for 5 of 5 sampled residents (#s 1, 2, 3, 6 and 7) who had documented changes of condition. Resident 2 was struck multiple times by another resident which caused undue distress and fear. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 08/2019 with diagnoses including dementia.a. During the acuity interview, Resident 2 was reported to have been involved in a resident-to-resident altercation where an unsampled resident hit Resident 2 multiple times with a walking device.According to a progress note dated 03/09/23, "Resident reported to the MT at 10:37 am, a resident 'jabbed' there [sic] walking stick 6 times below [his/her] left breast area. Resident stated that [unsampled resident] did it because [s/he] thought it was funny. Resident also stated incident happened because [Resident 2] touched [his/her] walking stick and that [s/he] stated 'I'll teach not to touch my cane' and proceeded to 'jab' resident."Resident 2 was sent to the emergency department on 03/09/23 and returned with diagnoses including blunt trauma to chest.In an interview on 03/22/23, Resident 2 summarized what occurred during the resident-to-resident altercation and was then asked about whether s/he felt safe in the community. S/he reported, "I don't like passing [him/her]. I'm scared to death. [S/he] has a cane that [s/he] uses, what if [s/he] hits me with it again?"The resident's progress notes dated 02/09/23 through 03/20/23, Temporary Service Plan (TSP) dated 03/09/23, incident report dated 03/09/23, and investigation (no date documented) were reviewed.A TSP was created on 03/09/23 which instructed care associates to report to the licensed nurse or designee the following:* "Pain in front torso"; and * "Must be monitored and kept away from [unsampled resident] at all times. Protect [Resident 2] from being hit by [unsampled resident]. [Resident 2] loves to touch people and [the unsampled resident] does not like to be touched."Although a TSP was created on 03/09/23, there was no documentation by the caregiving staff the TSP was reviewed until 03/12/23. The TSP did not instruct staff to monitor the resident for fear or other emotional trauma related to the incident.Progress notes dated 03/09/23 through 03/20/23 revealed Resident 2 was monitored for pain following return from the emergency department from 03/10/23 through 03/15/23. The first documented monitoring around whether the two residents were kept separate occurred on 03/18/23 or nine days following the resident-to-resident altercation. There was no documentation on the resident's emotional state in relation to the altercation.Multiple observations were made of Resident 2 during the re-licensure survey. Resident 2 attended activities, assisted other residents with simple tasks during activities, stood very closely to this surveyor and others during conversation, and spent time on the first and second floors. The unsampled resident, who was involved in the resident-to-resident altercation, was not observed in communal areas during the re-licensure survey.Resident 2 was interviewed on 03/22/23 and 03/24/23. During both interviews, s/he reported to have seen the unsampled resident on the first floor during the week of the re-licensure survey and wanted to kick the resident with his/her foot.On 03/23/23, Staff 5 (Health and Wellness Coordinator) was asked about whether the facility monitored the resident's fear associated with the resident-to-resident altercation. She said monitoring occurred around pain and separating the two residents. No additional documents were provided.The facility failed to evaluate Resident 2's fear and/or emotional trauma, develop interventions to mitigate the resident's continued emotional distress and communicate those interventions to staff on all shifts following a resident-to-resident physical altercation that resulted in pain, bruising and swelling for the resident. These failures resulted in ongoing fear and emotional turmoil for Resident 2. In an interview on 03/24/23 with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical), the facility's failure to evaluate the resident's emotional state, develop and communicate interventions to staff, and the resulting continued emotional distress for Resident 2 was discussed. They acknowledged the findings, and no additional information was provided.b. Resident 2's progress notes, dated 02/09/23 through 03/20/23 were reviewed. The following changes of condition lacked documented evidence monitoring instructions and/or interventions were communicated to staff with progress noted, at least weekly, through resolution:* 02/09/23 - New atorvastatin prescription for hyperlipidemia initiated;* 03/03/23 - Wandering/elopement event; * 03/09/23 - Left torso bruising/swelling; and* 03/09/23 - New PRN oxycodone prescription that had been administered for pain.The need to ensure the facility communicated changes of condition including monitoring instructions and interventions to staff and documented progress, at least weekly, until the conditions resolved was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23. They acknowledged the findings.
4. Resident 6 was admitted to the facility in 08/2017 with diagnoses including schizophrenia with intermittent suicidal ideations. Observations of the resident, interviews with staff, review of the resident's service plan dated 03/17/23, Temporary Service Plans and progress notes dated 12/20/22 through 03/21/23 were reviewed. The following short-term changes of condition lacked documentation of monitoring, at least weekly, through resolution for Resident 6's return from ER visits or hospitalizations to the facility after suicidal ideations on the following dates:* 12/20/22;* 01/05/23;* 01/12/23; and* 02/08/23.During an interview on 03/22/23 at 11:19 am, Staff 5 (Health and Wellness Coordinator) acknowledged the short term changes of condition were not monitored weekly until resolution. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/22/23 at 2:45 pm. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 06/2022 with diagnoses including chronic pain and hypertension.Resident 1's service plan available at the time of the survey, dated 11/10/22, noted the resident was dependent on staff for ADL care requiring one to two person assist at times. Resident 1 was noted to be independent with food and meal choices.Review of Resident 1's weight record noted the following:* 06/2022 - 244 pounds;* 07/2022 - 260 pounds (an increase of 16 pounds in one month);* 08/2022 - no weight; and* 09/2022 - 268 pounds (an additional eight pound weight gain). Between 06/2022 and 09/2022 Resident 1 gained 24 pounds or 8.9% of his/her body weight resulting in a significant change of condition. Additional weights were documented:* 10/2022 - 271 pounds;* 11/2022 - no weight;* 12/2022 - no weight; and* 01/2023 - 250.4 pounds.Between 10/2022 and 01/2023 Resident 1 lost 20.6 pounds or 7.6% of his/her body weight resulting in a significant change of condition.Resident 1 experienced significant weight fluctuations between 06/2022 and 01/2023. There was no documented evidence the facility RN assessed Resident 1's weight fluctuations to include findings, resident status and interventions made as a result of the assessment. Resident 1 was observed during the survey on 03/22/23 and 03/23/23 to eat independently and ate 100% of a breakfast and lunch meal. Resident 1's weight at the time of the survey was 260.8 pounds.The lack of RN assessment was discussed with Staff 1 (District Director of Operations), Staff 2 (District Director of Clinical) and Staff 4 (RN Oversite) on 03/23/23 at 11:00 am. Staff 4 completed an assessment of Resident 1 on 03/24/23.
3. Resident 3 was admitted to the facility in 01/2022 with diagnoses including diabetes and anxiety disorder.A progress note dated 03/18/23 noted return from a skilled nursing facility for rehabilitation after a hip fracture. There was no documented evidence the facility RN was notified or had completed a significant change of condition assessment that included documented findings, resident status and interventions made as a result of the assessment.The need to ensure the RN was notified and an assessment was completed following a significant change of condition was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/22/23. They acknowledged the findings. Staff 4 (RN Oversite) completed an assessment of Resident 3 on 03/22/23.
Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed timely for 3 of 3 sampled residents (#s 1, 3 and 6) who experienced significant changes of condition. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 08/2017 with diagnoses including blindness.Resident 6's service plan available at the time of the survey, dated 03/16/23, noted the resident required assistance to open food containers and to orient resident to location of food on plate. Resident 6 was noted to be independent with food and meal choices but required assistance to fill out the menu.Resident 6 was observed during lunch meals on 03/21/23 and 03/23/23 to eat independently and ate 75% of meals.During an interview on 03/22/23 at 10:55 am, Staff 15 (CG) reported Resident 6 was independent with his/her food choices, demonstrated no issues with nutrition and ate well. She reported Resident 6 had lost weight. Resident 6's weight records were reviewed and revealed the following:* 10/27/22 - 196 pounds;* 11/15/23 - 192.6 pounds (a decrease of 3.6 pounds); * 12/2023 - no weight; * 01/15/23 - 176.4 pounds (an additional decrease of 16.2 pounds);* 02/2023 - no weight; and* 03/2023 - no weight.During the survey, Staff 4 weighed Resident 1 on 03/21/23, which was 178.2 pounds.From 10/27/23 to 01/15/23, Resident 6 had a weight loss of 19.6 pounds or 10% of his/her body weight. This weight loss indicated a significant change of condition and required an RN assessment. There was no documented evidence the facility RN completed an assessment of Resident 6's significant weight loss to include findings, resident status and interventions made as a result of the assessment. On 03/22/23 at 11:45 am, Staff 4 (RN Oversite) confirmed there was no nursing assessment for the weight loss. The need to ensure all significant changes of condition were assessed by an RN and were completed in a timely manner was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/22/23 at 2:40 pm. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control for 1 of 1 sampled resident (# 1) who had a catheter. Findings include, but are not limited to:Observations were made during the survey to determine adherence to universal precautions for infection control.During observations of the resident's apartment on 03/21/23, 03/22/23 and 03/23/23 the following was noted: * On 03/21/23 and 03/22/23 multiple observations of Resident 1's catheter bag lying directly on the floor;* On 03/21/23 through 03/23/23, Resident 1's apartment had a urine odor;* The floor was sticky/tacky; and* Commode had brown matter in and around the perimeter.Infection control and the condition of the resident's apartment was discussed with Staff 1 (District Director of Operations), Staff 2 (District Director of Clinical) and Staff 4 (RN Oversite) at 11:00 am on 03/23/23. Resident 1's apartment was cleaned on 03/23/23.

2. Resident 1 was admitted to the facility in 06/2022 with diagnoses including chronic pain and hypertension.During an interview and observation on 03/21/23, Resident 1 stated his/her family filled up a medication set weekly for the resident to administer his/her own medications. Bottles of prescription medications and the medication weekly organizer was observed in the resident's apartment.The self-administration of medication evaluation was completed on 11/01/22 and noted family was filling the medication organizer and the resident was unable to identify medications, doses or indications for use. The recommendation included having the facility take over medication administration. There was no documented evidence the self medication evaluation had been completed quarterly since 11/01/2022 addressing recommendations from the previous evaluation.Quarterly evaluations of self-administration of medications was discussed with Staff 1 (District Director of Operations), Staff 2 (District Director of Clinical) and Staff 4 (RN Oversite) on 03/23/23 at 11:00 am. Staff acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications and had more than one resident residing in the apartment, were evaluated upon move-in and quarterly to assure the residents' ability to safely self-administer medications and to safely have medications in the unit for 2 of 2 sampled residents (#s 1 and 5) who were reviewed for self-administration. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 01/2023 with diagnoses including hypertension, osteoarthritis and depression.During the acuity interview on 03/21/23, Resident 5 was identified as self-administering all his/her medications and lived in the same apartment with his/her spouse. In an interview on 03/22/23, Resident 5 confirmed s/he self-administered his/her medications, did not keep medications in a locked storage and facility staff administered medications to the spouse. Review of Resident 5's records revealed there was no documented evidence the resident was evaluated upon move-in for his/her ability to safely self-administer medications and the resident's spouse was not evaluated for the ability to safely have medications in the unit.The need to ensure residents who chose to self-administer their medications and had more than one resident residing in the unit were evaluated upon move-in was reviewed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23 at 11:35 am. They acknowledged the findings.

Based on interview and record review it was determined the facility failed to ensure updated information was added to their Acuity Based Staffing Tool (ABST). Findings include: In an interview on 03/24/23, Staff 1 (District Director of Operations) stated the company's ABST was driven by the same information used to create the service plans.During the relicensure survey, multiple sampled residents were found to have service plans that were not updated quarterly and/or were not reflective of the resident's status.The need to implement an ABST based on accurate and updated information was discussed with Staff 1 and Staff 2 (District Director of Clinical) on 03/24/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. This is a repeat citation. Findings include, but are not limited to:The facility's ABST was reviewed on 09/19/23 and discussed with Staff 1 (District Director of Operations) on 09/19/23 at 4:00 pm. She reported the ABST was populated by the Resident Assessment, which was driven by the service plan for each resident.There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using. The need to have all required ADLs on the ABST, and to ensure service plans were reflective so the ABST would be accurate, was discussed with Staff 2 (District Director of Clinical) and Staff 33 (Executive Director II) on 09/20/23. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. This is a repeat citation. Findings include, but are not limited to:The facility's ABST was reviewed and discussed with Staff 33 (Executive Director II) on 12/06/23. He reported the ABST was populated by the Resident Assessment, which was driven by the service plan for each resident.There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using. The need to have all required ADLs on the ABST was discussed with Staff 33 and Staff 34 (Health and Wellness Director III) on 12/06/23. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 10, 23, 24 and 31) completed all elements of pre-service orientation and dementia training prior to providing care to residents. Findings include, but are not limited to:Staff training records were reviewed on 03/22/23 and 03/23/23. a. Staff 10 (CG), hired 01/06/23, Staff 23 (CG), hired 01/06/23, Staff 24 (MT), hired 01/31/23, and Staff 31 (Server), hired 01/25/23, lacked written job descriptions.b. Staff 10 lacked documented evidence of being trained in the dementia disease process including progression, memory loss, psychiatric and behavioral symptoms.c. Staff 31 lacked documented evidence of training in the following elements:* Resident rights and values of CBC care; and* Infectious disease prevention.The need for all newly hired staff to complete all required elements of pre-service orientation and dementia training in the specified time frame was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical). No additional information was received.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired staff (#24) completed all required training and demonstrated competency in all assigned job duties. The facility failed to ensure 2 of 3 staff (#s 25 and 16) had documented evidence of demonstrated competency in all assigned job duties. Findings include, but are not limited to:Training records were reviewed on 03/22/23 and 03/23/23. a. Staff 24 (MT), hired 01/31/23, lacked documentation of training in the following elements:* General food safety, serving and sanitation; * Demonstration of satisfactory performance relating to all assigned job duties (including medication administration); and* Abdominal thrust and First Aid. Survey requested Staff 24 to be removed from the schedule as an MT until she had documentation of demonstrated satisfactory performance in all assigned job duties. Staff 24 was removed from the schedule.b. Staff 16 (MT/CG), hired 04/25/22, and Staff 25 (MT), hired 03/22/22, lacked documentation of demonstrated satisfactory performance in all assigned job duties including medication administration. Staff 1 (District Director of Operations) reported Staff 25 had completed all required training prior to her job duties, but they were unable to locate the documents.Survey requested Staff 16 and Staff 25 obtain the documentation of demonstrated satisfactory performance in all assigned job duties prior to working their next shift. Documentation was completed on 03/23/23.The need to ensure direct care staff completed all required training and had documentation of demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 and Staff 2 (District Director of Clinical) on 03/23/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to verify 2 of 4 newly hired direct care staff (#s 39 and 40) had demonstrated satisfactory performance in any duty they were assigned. This is a repeat citation. Findings include, but are not limited to:Training records were reviewed on 09/19/23 and 09/20/23. Staff 39 (MT), hired 08/18/23 and Staff 40 (CG) hired 08/04/23, lacked documentation of training in the following elements:* Providing assistance with ADLs;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting; and * Medication administration duties. On 09/20/23 at 10:35 am, the surveyor shared the above findings with Staff 38 (Business Office Manager). Staff acknowledged the findings.The need to ensure direct care staff completed required training's and had documentation of demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 33 (Executive Director II) on 09/20/23. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 12, 27 and 28) completed the required minimum 12 hours of in-service training annually which included six hours of dementia care training. Findings include, but are not limited to:Staff training records were reviewed on 03/22/23 and 03/23/23.There was no documented evidence Staff 12 (CG), Staff 27 (MT) and Staff 28 (MT), hired 06/28/10, 08/28/17, and 01/09/19, respectively, had completed the required minimum 12 hours of in-service training annually related to the provision of care which also included six hours of dementia care training.The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23. No additional information was provided.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month and to provide fire and life safety instruction to staff on alternate months, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire and life safety records were reviewed on 03/22/23 at 8:45 am.The facility provided documentation of two fire drills in the last six months, which occurred on 02/01/23 and 02/27/23. There was no documented evidence fire drills were conducted every other month.On 02/01/23, staff were instructed on Fire Drill Policy. There was no documented evidence staff were instructed on fire and life safety on alternating months from fire drills. During an interview on 03/22/23 Staff 8 (Maintenance Supervisor) indicated the fire drills and fire and life safety instruction to staff only occurred in 02/2023 over the last six months.The need to ensure fire drills were conducted and staff instruction was provided according to the OFC was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/22/23 at 2:30 pm. They acknowledged the findings and no further information was provided.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and at least annually thereafter. Findings include, but are not limited to:Fire and life safety records were reviewed on 03/22/23 at 8:45 am and revealed a lack of documented evidence related to the following required elements:* Instructions to residents on fire and life safety procedures within 24 hours of admission; and* A written record, including content and residents attending, of annual re-instruction for residents on general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places inside or outside the building in the event of an actual fire.The need to provide training to residents on fire and life safety as required by the Oregon Fire Code was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/22/23 at 2:30 pm. They acknowledged the findings and no further information was provided.

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 231, C 260, C 361 and C 372.
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.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the facility's common use areas were made of smooth material and maintained in good repair. Findings include, but are not limited to:The exterior of the facility was toured on 03/21/23 at 10:13 am. The following issues were noted:* The facility's common use pathways had multiple expansion joints which measured approximately one inch wide. This constituted a tripping hazard;* The outside perimeter of the pathway surrounding the building had multiple areas where sod and pavement did not meet. This created an approximate one inch wide and one to two inch deep drop-off; and* Large and uneven cracks in pathway concrete on north side of the building.The need to ensure common use areas were free from drop-offs was discussed with Staff 1 (District Director of Operations), Staff 8 (Maintenance Supervisor) and Staff 32 (Housekeeping Supervisor) on 03/24/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure interior and exterior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:The interior of the building was toured on 03/21/23 at 11:05 am. The following areas were observed to need cleaning and/or repair:* Baseboards in dining room had brown drips, stains and dust;* Walls throughout the dining room had drips, gouges, chipped paint, cracks and holes;* Dining room tables had worn sealant around edges with bare wood exposed;* Chairs throughout the dining room were stained and had scrapes and/or gouges in the wood; * Drywall below resident mailboxes was gouged;* Women's public bathroom on the first floor had lifted baseboard and gouges in the drywall;* Resident laundry room was missing an electric outlet cover;* Ceiling tiles above the first floor shower room were stained brown;* Multiple resident rooms had white drips and were scraped or gouged doors with bare wood exposed;* Multiple resident metal door frames were dented and/or broken;* Walls throughout the facility had chipped paint, scrapes and gouges;* Handrail near room 100 was split which created potential for skin tears; * Interior elevator paneling was gouged;* Chairs throughout the second floor activity room had scrapes and gouges in the wood; * Cabinet door under the sink in the activity room was broken;* Handrails and the door frame surrounding room 200 were coated in tan stains;* Furniture throughout all resident hallways was stained and the legs of the furniture were scraped with bare wood exposed;* Windowsills near third floor seating area had cobwebs, debris and dust; and * Chandelier above staircase had multiple burned out and flickering lightbulbs.The exterior of the building was toured on 03/21/23 at 10:13 am. The following areas were observed to need repair:* Siding throughout the property was damaged with corner pieces missing or not fully attached;* Siding near second and third floor patios was lifted with rusted metal exposed;* Exterior security door near room 119 had rips and holes; * Multiple exterior patio doors were faded, had gouges, scrapes and/or chipped paint;* Multiple exterior patio door frames were faded, had gouges, scrapes and/or chipped paint; and* Window screens for multiple resident rooms were threadbare and/or had large holes.The surveyor toured the environment with Staff 1 (District Director of Operations), Staff 8 (Maintenance Supervisor) and Staff 32 (Housekeeping Supervisor) on 03/24/23. They acknowledged the above areas needed to be cleaned and repaired.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' apartments were maintained within a range of 110 - 120 degrees Fahrenheit. Findings include, but are not limited to:On 03/22/23 and 03/23/23, resident apartments were toured and water temperatures were taken throughout the building. Water temperatures were higher than 120 degrees Fahrenheit in the following apartments:* Room 204 - 124.6 degrees Fahrenheit;* Room 223 - 123.6 degrees Fahrenheit;* Room 303 - 123.4 degrees Fahrenheit; and* Room 331 - 130.0 degrees Fahrenheit.The need to adjust the water temperatures between 110 degrees and 120 degrees Fahrenheit was discussed with Staff 1 (District Director of Operations) on 03/22/23 at 3:47 pm. Water temperatures were taken again with Staff 8 (Maintenance Supervisor) on 03/23/23 throughout the course of the day. All temperatures obtained were between 110 and 120 degrees Fahrenheit.The need to ensure water temperatures in residents' apartments were maintained within a range of 110 to 120 degrees Fahrenheit was discussed with Staff 1 and Staff 8 on 03/24/23. They acknowledged the findings.

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 3/7/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 01/17/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 01/17/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 01/17/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 01/17/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 01/17/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day