Skylark Memory Care

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

1. On 10/21/25, from 10:20 am through 12:45 pm, the facility dinning room was observed.

a. The following areas needed cleaning:

• Beverage station countertop had spills;
• Juice machine - an accumulation of splatters;
• Wall next to the coffee maker had brown residue; and
• One fan had accumulated dust and was blowing directly onto the plastic rack where clean utensils were stored.

b. The following areas needed repair:

• Cabinet under the sink in the dining room had water damage.

2. On 10/21/25, from 10:20 am through 12:45 pm, the facility main kitchen was observed.

a. The following areas needed cleaning:

• Juice machine - an accumulation of splatters;
• Multiple fans had a buildup of dust;
• Deep fryer had grease buildup on the front and sides;
• Three-compartment sink contained dirty items, including pans and pots from the previous night;
• Paper towel dispenser had spills;
• Handwashing sink was stained inside;
• Handwashing sink, especially around the faucet area, had brown residue;
• Walls throughout the kitchen, especially near the handwashing sink and the pre-clean station, dishwasher area, and three-compartment sink had spills, food debris and grease buildup;
• Vent above the three-compartment sink and two-door refrigerator had accumulated dust;
• Ceiling throughout the kitchen, especially around the dishwasher and above the oven area had spills and grease buildup;
• Inside the one-door freezer was a buildup of ice;
• Rack used for storing clean utensils was rusty and the vent next to the rack area had rust and accumulated dust;
• Commercial can opener had black reside inside;
• The walk-in freezer had a large ice buildup on the floor;
• Janitor’s closet floor and walls had accumulated black residue;
• Multiple sprinkler heads had spiderwebs and rust;
• Oven and grills had heavy grease buildup front, side and back;
• Floor and baseboards around the dishwasher area the corners of the kitchen had black buildup;
• Drains throughout the kitchen had black residue buildup;
• The ice machine had accumulated dust on the side and rear piping area; and
• Inside of the steamer had brown residue.

b. The following areas needed repair:

• The top panel of the freezer was detached and hanging; and
• The exterior of the soup warmer had multiple chips.
3. Improper food storage:

• Multiple chopped vegetables and food items in the salad cooler, including sliced ham, macaroni, carrot salad, and chopped lettuce were undated;
• The brown sugar container had a scoop inside;
• Storage rack had multiple food items, including several open cereal bags were undated;
• One-door freezer contained multiple open packages of frozen meat were not completely sealed and were undated;
• Two-door refrigerator had several open food items including bottles of dressing and milk were undated; and
• In the walk-in cooler, multiple food items including cheese and milk were undated and a container of chopped tomatoes was undated and appeared to have white fungus on top.
4. Other areas of concern include:

• Silverware on the preset dining tables was not wrapped or covered;
• Multiple trash cans were uncovered when not in use;
• Multiple staff were observed placing their thumbs inside clean cups and bowls while handling them;
• Multiple kitchen staff were not properly restraining their hair;
• Staff failed to change between clean and dirty tasks; and
• Staff failed to use alcohol wipes to clean the thermometers after each use.

5. On 10/21/25, from 10:20 am thru 12:45 pm, the facility’s Cottage one kitchenette was observed, and the following areas were noted:

• Inside the cabinet, a container of peanut butter, cocoa powder, and multiple cereal bags were undated;
• Baseboard next to the juice dispenser showed signs of water damage;
• Inside the cabinet, below the juice dispenser, brown residue had accumulated; and
• Juice dispenser had a sticky buildup.

6. On 10/21/25, from 10:20 am though 12:45 pm, the facility’s Cottage two kitchenette was observed, and the following areas were noted:

• Inside the cabinet, a container of peanut butter and a bottle of light corn syrup were undated;
• An open bag of powdered sugar was not completely sealed and was undated;
• Cabinet below the juice dispenser showed signs of water damage;
• Juice dispenser had a sticky buildup; and
• Baseboard at the entrance of the kitchenette showed signs of water damage.

The areas of concern were observed and reviewed with Staff 1 (ED) and Staff 2 (Regional Director) on 10/21/25 at 12:48 pm. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to:

Refer to C240

The findings of the annual kitchen inspection, conducted on 07/24/24, 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 revisit to the kitchen inspection of 07/24/24, conducted 10/30/24 thru 10/31/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchen, food storage, food preparation areas, and the Memory Care's kitchenettes on 07/24/24 noted the following in need of cleaning or repair:a. Main Kitchen* The reach in freezer to the right of the kitchen entrance door had food debris present on the lowest shelf; * The room where the reach in freezer was located had a gouge in the wall, chipping paint, and the light switch face was broken; * The reach in freezer to the right of the steam table had icicles present and there was a bag of food open to air; * The grill to the left of the oven had a build-up of black and brown matter present; * Both sides of the deep fryer were observed to have a build-up of debris; * Inside, outside, and the backsplash of the stove had brown and black matter present;* The garbage can to the right of the stove had built-up food matter and debris on the top and sides; * The lower shelves of the steam table had food debris present; * There was undated and unlabeled food located in the deli cart's refrigerator; * There was a dirty rag and coffee grounds in the drain in front of the coffee maker;* The cupboard under the hand washing sink had spills present; * There were small holes in the wall behind the hand washing sink and the area was missing some paint; * There was debris present outside of the reach in refrigerator's door; * There were multiple food items in the walk-in refrigerator that were not covered, labeled, or dated; * Boxes were observed to be stored on the floor in the walk-in freezer; * Cutting boards throughout the kitchen, including the one attached to the deli cart, had deep grooves and score marks present deeming them to be uncleanable; * The shelf above the one compartment sink was sticky to the touch; * The garbage can to the left of the one compartment sink had built-up debris on the top and the sides; * The blade on the industrial can opener had built-up food debris present; * The two spice shelves had a layer of debris present; * The faucet in the dish washing area had a constant drip; * Walls throughout the kitchen had drips, splatters, food debris, scuffs, and chipped paint; * The ceiling panel outside of the walk-in refrigerator was missing, and there were other ceiling panels in the front of the kitchen that were lifting up; * Vents in the ceiling located by the stove area and by a large wire storing rack in the back of the kitchen had an accumulation of dust; * A fan located to the right of the three compartment sink was covered in a thick layer of dust; and * Floor drains throughout the kitchen had brown and black matter present. b. Kitchenettes* The cabinets and doors leading into the kitchenettes had chipped paint; * There were drawers observed to have debris inside of them; * The cupboards had areas on the outside where the paint was chipping off; and * Inside of the standing refrigerator and freezer units, there was food debris observed. The areas in need of cleaning and repair were reviewed with Staff 1 (Culinary Director), Staff 2 (Maintenance), and Staff 3 (Memory Care Program Director) on 07/24/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240.

The findings of the re-licensure survey, conducted 11/28/22 through 12/01/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily 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 daySituations were identified where there was a failure of the facility to comply with the Department's rules which were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas:OAR 411-054-0055 (1) Medication and Treatment Administration Systems; andOAR 411-057-0160 Behaviors.The facility put immediate plans of correction in place during the survey and the situations were abated.
The findings of the first revisit to the re-licensure survey of 12/01/22, conducted 06/06/23, 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, Division 57 for Memory Care Communities, and Division 004 for Home and Community Based Services.

Based on observation and interview, it was determined the facility failed to ensure all required postings were displayed in a conspicuous location for residents and visitors and available for inspection at all times. Findings include, but are not limited to:During a tour of the environment on 11/28/22, there were no postings related to the administrator or designee in charge or the current facility staffing plan in an accessible or conspicuous location.The findings were reviewed with Staff 2 (ED designee) on 11/29/22. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the preparation, completeness, and accuracy of documentation or records for 3 of 4 sampled residents (#s 1, 2, and 4) whose records were reviewed. Findings include, but are not limited to:During the survey, resident records were reviewed and were found to be missing, inaccurate, or incomplete in multiple areas, including signed physicians' orders, service plans, evaluations, monitoring, incident investigations, and outside provider notes. On 12/01/22, the need to ensure facility records were accurate and complete was shared with Staff 2 (ED designee) and Staff 3 (Consultant). No additional information was provided.

2. Resident 4 was admitted to the facility in 04/2022 with a diagnosis of dementia.The resident's service plan, dated 04/27/22, progress notes from 08/31/22 through 11/28/22, interim service plans (ISPs), and incident reports were reviewed. The following incidents were identified:* 09/23/22 - a fall resulting from another resident running over his/her foot with their wheelchair;* 10/22/22 - resident reported pain in right heel; staff wrote in a progress note the pain seemed to be from a "gash" in the heel. In the progress note, staff stated "Resident enjoys spending time in the courtyard where there are many sharp rocks and other potentially hazardous materials on the ground that could cause injury"; and* 11/26/22 - staff discovered a cut on the resident's left forearm "that was bleeding which appeared to be from dry skin [sic]."There was no documented evidence these incidents were investigated to rule out abuse and/or neglect, reported to the local SPD office if needed, or reviewed by the administrator.The need to promptly investigate all incidents of abuse or suspected abuse and report to the local SPD if needed was discussed with Staff 2 (ED designee), Staff 3 (Consultant), and Staff 4 (Consultant) on 11/30/22. No additional information was provided.
Based on interview and record review, it was determined the facility failed to investigate incidents of possible abuse or neglect to rule out abuse or neglect, and to report to the local SPD office if needed, for 2 of 2 sampled residents (#s 2 and 4) who were identified to have incidents of possible abuse or neglect, including falls and injuries. Findings include, but are not limited to:1. Resident 2 was admitted to the facility 12/2021 with diagnoses including Parkinson's disease and cognitive communication deficit.A chart noted dated 10/22/22 stated: "FAMILY COMMUNICATION: resident's son called this med tech about 30 minutes ago to inquiring [sic] regarding alleged abuse and neglect that was witnessed by his sister and niece yesterday on evening shift. Family members state caregivers acted inappropriately by ignoring calls for help while they sat on their phones, dry BM [bowel movement] was in [his/her] chair and in [his/her] bed, an old sandwich was found under the bed, caregiver that changed [him/her] stated 'ew ...gross' when changing BM soiled brief."There was no documented evidence the incident was reviewed by the administrator, investigated, or reported to SPD as necessary.In an interview on 11/29/22, Staff 1 (Memory Care Program Designee/LPN) was unable to confirm that the incident had been investigated. Staff 2 (ED designee) was requested by surveyor on 12/01/22 to report the incident to the local SPD office. Confirmation the incident had been reported was provided to the survey team on 12/01/22.The need to ensure incidents of possible abuse were reviewed by the administrator and immediately investigated to rule out abuse and/or neglect, and reported to the local SPD office when abuse and neglect could not be ruled out, was discussed with Staff 3 (Consultant) and Staff 4 (Consultant) on 11/30/22. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide an activity program based on individual and group interests and opportunities for active participation in the community at large. Findings include, but are not limited to:During the survey, there was a lack of unscheduled and scheduled activities that occurred for residents who were unable to self-initiate activities or for the community at large.No group activities were observed in Cottage 1 or Cottage 2 between 11/28/22 and 11/30/22.Board games scheduled for 1:00 pm in Cottage 1 on 11/30/22 did not occur. Staff 9 (Resident Assistant) reported no activity staff was on the unit.The need to ensure an activity program was implemented to meet the needs of the residents was discussed with Staff 2 (ED designee), Staff 3 (Consultant), and Staff 4 (Consultant) on 11/30/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to complete quarterly evaluations for 3 of 3 sampled residents (#s 1, 2, and 4) whose records were reviewed. Findings include, but are not limited to:Records for Residents 1, 2, and 4 were reviewed, and there was no documented evidence resident evaluations were updated quarterly.1. Resident 1's clinical record contained an evaluation dated 03/17/22. The next quarterly evaluation would have been due on 06/17/22. There was no documented evidence an evaluation had been completed after 03/17/22.2. Resident 2's clinical record contained an evaluation completed 02/01/22. The next quarterly evaluation would have been due on 05/01/22. There was no documented evidence an evaluation had been completed after 02/01/22.3. Resident 4's clinical record contained an evaluation completed when the resident was admitted, dated 04/27/22. The next quarterly evaluation would have been due on 07/27/22. There was no documented evidence an evaluation had been completed after 04/27/22.On 11/30/22, the need to ensure the facility performed evaluations at least quarterly, to correspond with the quarterly service plan updates, was discussed with Staff 1 (ED Designee), Staff 3 (Consultant), and Staff 4 (Consultant). No additional information was provided.

2. Resident 4 was admitted to the facility in 04/2022 with a diagnosis of dementia.The resident's service plan, dated 04/27/22, and progress notes, dated 08/31/22 through 11/28/22, were reviewed and staff were interviewed. The service plan was not reflective of the resident's current status and care needs in the following areas:* Toileting needs; and* Behaviors.There was no documented evidence the resident's service plan had been updated since 04/27/22.The need to update service plans within 30 days of admission and quarterly thereafter, as well as the need for service plans to be reflective of the resident's current status and care needs and provide clear direction to staff on the provision of care, was discussed with Staff 2 (ED designee), Staff 3 (Consultant), and Staff 4 (Consultant) on 11/30/22. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure resident service plans were followed, were reflective of resident needs, were readily available to staff, provided clear instructions to staff, and/or were updated quarterly for 2 of 2 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Review of Resident 2's service plan and interim service plans (ISPs), observations of the resident, and interviews with staff identified the following:a. The most recent service plan was dated 02/01/22. There was no documented evidence the service plan was updated quarterly.b. The service plan was not reflective and lacked clear direction to staff in the following areas:* Feeding;* Bathing; and* Repositioning.c. The most recent service plan was in a binder in the MT room, making it not readily available to staff.d. The resident's service plan was not followed in the following areas:* Every 2 hours toileting checks;* Every 2 hours repositioning; and* Every 2 hours hydration.On 11/29/22 at 11:10 am, Staff 13 (Resident Assistant) reported she had last provided incontinence care, repositioning, and hydration for the resident at 8:00 am.The need to ensure service plans were reflective of resident needs, included clear direction and were available to staff, were followed, and were updated quarterly was discussed with Staff 3 (Consultant) and Staff 4 (Consultant) on 12/01/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 04/2022 with a diagnosis of dementia.A review of the resident's record revealed s/he experienced multiple short-term changes of condition between 08/31/22 and 11/28/22, including falls, injuries, medication changes, and behaviors.There was no documented evidence the facility consistently determined what actions or interventions were needed, communicated the actions or interventions to staff on each shift, documented resident-specific staff instructions or interventions and made them part of the resident's record, or monitored changes with weekly progress noted through resolution.The need to monitor short-term changes of condition through resolution was discussed with Staff 2 (ED designee), Staff 3 (Consultant), and Staff 4 (Consultant) on 11/30/22. No additional information was provided.
Based on interview and record review, it was determined the facility failed to identify and evaluate changes of condition, determine resident-specific actions or interventions needed, provide written communication of those interventions to staff on each shift, and/or monitor the conditions to resolution for 2 of 2 sampled residents (#s 2 and 4) who experienced changes of condition. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including Parkinson's disease and cognitive communication deficit.A review of the resident's record revealed s/he experienced multiple short-term changes of condition between 08/28/22 and 11/28/22, including behaviors, skin issues, and medication changes.There was no documented evidence the facility monitored these changes through resolution.The need to monitor changes of condition through resolution was discussed with Staff 3 (Consultant) and Staff 4 (Consultant) on 11/30/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 04/2022 with a diagnosis of dementia.The resident's 04/27/22 service plan, 08/31/22 through 11/28/22 progress notes, and ISPs were reviewed.A progress note and interim service plan, both dated 11/18/22, revealed the resident had been admitted to hospice that day. There were no hospice visit notes located in the resident's chart, nor was there any documented coordination of care between the facility and hospice.The need to coordinate care with outside providers and ensure service providers left written information in the facility addressing services being provided to the resident and any clinical information necessary for staff to provide supplemental care was discussed with Staff 2 (ED designee), Staff 3 (Consultant), and Staff 4 (Consultant) on 11/30/22. No further information was provided.
Based on interview and record review, it was determined the facility failed to ensure outside service providers left written information in the facility which addressed the on-site services being provided to the resident and failed to coordinate care with outside providers to ensure continuity of care for 3 of 3 sampled residents (#s 1, 2 and 4) who received services from an outside provider. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 02/2021 with diagnoses including dementia, diabetes, and edema. The resident was identified during the acuity interview on 11/28/22 as having skin issues related to leg cellulitis.Resident skin notes were requested. One chart note was provided: 11/21/22 "SKIN NOTE: ...Left leg has weeping of clear fluid on lower leg. Home Health notified ..."Staff 1 (MC Program Designee/LPN) stated in an interview on 11/29/22 that she did not have additional skin notes or home health notes.No additional information was provided.2. Resident 2 was admitted to the facility in 12/2021 with diagnoses including Parkinson's disease and cognitive communication deficit. The resident was identified during the acuity interview on 11/28/22 as being on hospice.* Staff 15 (MT) and Staff 1 reported in interviews on 11/28/22 and 11/29/22, respectively, that the process for communication with outside providers sometimes included providers faxing their notes after the visit.* A chart note dated 11/26/22 stated: "OUTSIDE PROVIDER COMMUNICATION: ... HOSPICE NOTE RN: ...PLEASE DO NOT GIVE [HIM/HER] FOOD. IT IS OKAY TO GIVE GOOD AND FREQUENT ORAL CARE AND SIPS OF WATER ONLY IF S/HE IS AWAKE AND ABLE TO SAFELY SWALLOW."An observation was made on 11/28/22 of a paper sign taped on the wall at the head of the bed in resident's room: "Please don't feed resident food. Sips of water OK only if awake. Provide constant oral care."There was no documented evidence the resident's service plan had been updated with the recommendation from the hospice RN.A request was made of Staff 1 on 11/30/22 for the hospice RN note from which the chart note on 11/26/22 was based. A hospice RN visit note dated 11/26/22 was provided on 12/01/22 with a fax transmittal date/time of 11/30/22 9:00 pm.No written hospice notes for Resident 2 were provided during the survey.The need to ensure outside providers left written information for each of their visits and the facility reviewed the information and updated the resident's service plan or orders accordingly was discussed with Staff 3 (Consultant) and Staff 4 (Consultant) on 11/30/22. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Residents were put at risk related to not having physician orders and lack of competency training for employees who administered medications. The findings constituted an immediate plan of correction for the health and safety of residents. Findings include, but are not limited to:During the re-licensure survey, conducted 11/28/22 through 12/01/22, administrative oversight of the facility's medication system was found to be ineffective based on deficiencies in the following areas:* C303: Systems: Medication and Treatment Orders; and* Z155: Staff Training Requirements.On 11/30/22 at 11:15 am, the survey team requested an immediate plan of correction to address the issues identified. At 2:00 pm, a plan was received and accepted by the survey team. The immediate jeopardy situation was abated at that point in time.

Based on interview and record review, it was determined the facility failed to ensure signed physician orders for all medications and treatments the facility was responsible for administering were documented in the resident's facility record for 2 of 2 sampled residents (#s 2 and 4) whose records were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 04/2022 with a diagnosis of dementia.A review of the resident's 11/01/22 through 11/28/22 MAR and the resident's clinical record revealed the facility did not have signed physician orders for any medications or treatments on the MAR.The need to have signed physician orders for all medications and treatments administered by the facility was discussed with Staff 2 (ED designee), Staff 3 (Consultant), and Staff 4 (Consultant) on 11/30/22. No additional information was provided.
2. Resident 2 was admitted to the facility in 12/2021 with diagnoses including Parkinson's disease and cognitive communication disorder.The resident's 11/01/22 through 11/28/22 MAR and clinical record were reviewed. The following deficiencies were identified:a. The following medications were being administered without a signed written physician's order in the resident's record:* Haloperidol 2 mg/ml every 6 hours;* Lorazepam 0.5 mg tab 4 times daily;* Methadone 5 mg tab 0.5 tab (2.5 mg) every 12 hours;* Quetiapine 200 mg tab 0.5 tab (100 mg) every night;* Nicotine 21 mg/24 hr patch apply 1 patch to back daily;* Senna 8.6 mg tab 1 tablet every morning; and* Senna 8.6 mg tab 2 tablets (17.2 mg) every evening.b. The facility ceased administering the following medications without a signed physician's order to discontinue the medications in the resident's record:* Acetaminophen 500 mg caplets 1 tablet 4 times daily;* Furosemide 40 mg tab 1.5 tablet 2 times daily;* Melatonin 10 mg capsule every evening;* Metoprolol 25 mg tab every day;* Omeprazole 20 mg capsule every day;* Polyethylene glycol powder 17 grams in 4-6 oz of water/liquid daily;* Potassium CHL 20 MEQ tablet twice daily;* Quetiapine 200 mg tab 0.5 tab (100 mg) every night;* Senna 8.6 mg tab 1 tablet every morning;* Senna 8.6 mg tab 2 tablets (17.2 mg) every evening; and* Trazodone 50 mg tab every night.The need to have signed physician orders in the resident's record for all medications and treatments the facility was responsible to administer, and signed orders to discontinue medications, was reviewed with Staff 3 (Consultant) and Staff 4 (Consultant) on 11/30/22. 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. Findings include, but are not limited to:During an interview on 11/29/22 with Staff 2 (ED Designee) and Staff 3 and 4 (Consultants) the following was revealed:1. During a review of sampled residents' service plans, it was determined the ABST failed to accurately include activities of daily living, other tasks related to care due to service plans lacking updated and accurate information on resident care needs. 2. The facility did not have a system for conducting updates of the ABST tool for each resident as required, including:(a) Before a resident move-in, with amendments as appropriate within the first 30 days to address a resident's needs;(b) Whenever there was a significant change of condition; and(c) No less than quarterly, preferably at the same time the resident's service plan was updated.3. The facility was using an ABST tool which generated daily staff hours but was not consistently staffing to the levels identified. The ABST staff level noted two caregivers and two medication aides on day shift and swing shift and one caregiver and one medication aide on the overnight shift. Review of the 11/01/22 through 11/28/22 staffing schedule revealed 69 times the facility was not staffing according to the levels identified by the ABST tool.The ABST tool was reviewed and discussed with Staff 2, Staff 3, and Staff 4 on 11/29/22 at 3:15 pm. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly-hired direct care staff (#s 20 and 22) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:Training records were reviewed on 11/29/22 and identified the following:Staff 20 Resident Assistant (RA), hired on 09/15/22, and Staff 22 (MT), hired 11/04/22, lacked documentation of demonstrated competency in First Aid/abdominal thrust.The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 2 (ED designee) and Staff 3 (Consultant) on 11/29/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all required elements were documented for fire drills in accordance with Oregon Fire Code (OFC) and fire and life safety instruction was provided on alternate months. Findings include, but are not limited to:Review of fire drill and fire and life safety records from 05/30/22 through 08/20/22 identified the following:* The facility failed to provide fire and life safety instruction to staff on alternate months; * Escape route used;* Problems encountered, comments relating to residents who resisted or failed to participate in the drill;* Evacuation time needed;* Number of occupants evacuated; and* Alternate routes used during fire drills were not documented.In an interview with Staff 13 (Resident Assistant) and Staff 14 (MT) on 11/30/22, they were unable to identify the designated points of safety within or outside the building.The need to ensure the facility documented all required elements for fire drills was reviewed with Staff 2 (ED Designee) and Staff 3 (Consultant). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents annually. Findings include, but are not limited to:Fire drill records, from 04/30/22 through 10/03/22, were reviewed on 11/29/22.On 11/30/22 at 09:15 am, Staff 2 (ED designee) stated the facility was not providing or documenting annual instruction for residents in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 2 on 11/30/22. He acknowledged the findings.

Based on observation and interview, the facility failed to ensure toxic materials were properly labeled and stored. Findings include, but are not limited to:A tour of the facility was completed on 11/29/22. The laundry room in Cottage 1 was unlocked and contained toxic materials.In an interview with Staff 2 (ED designee) on 11/29/22 at 01:45 pm, he stated the closets should be locked.The need to ensure the facility properly labeled and stored toxic materials was discussed with Staff 2. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:Observations of the facility on 11/29/22 revealed the following areas were in need of cleaning or repair:A. Cottage One:* The interiors of the refrigerator and microwave had food spills and debris;* There were food splatters on wall under kitchenette counter;* The transition strip between the dining room and living room was loose and a possible tripping hazard; and* The linoleum in laundry room was cracked, peeling, and was an uncleanable surface.B. Cottage Two:* The interiors of the refrigerator and microwave had food spills and debris; and* Exit door to patio was scraped and missing paint.The areas in need of cleaning and repair were discussed with Staff 2 (ED Designee) on 11/29/22. He acknowledged the findings.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services rendered in the facility. Findings include, but are not limited to:During the re-licensure survey, conducted 11/28/22 through 12/01/22, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number and severity of citations issued during survey.1. A situation was identified which constituted an immediate threat to residents' health and safety in the following area:OAR 411-054-0055 (1)(a) Medication and Treatment Administration Systems.The facility put an immediate plan of correction in place during the survey and the situation was abated.2. A situation was identified which constituted an immediate threat to residents' health and safety in the following area:OAR 411-057-0160(e) Behavior.The facility put an immediate plan of correction in place during the survey and the situation was abated.3. Refer to deficiencies in the report.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 152, C 155, C 231, C 242, C 361, C372, C 420, C 422, C 510, and C 513.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 20, 21, and 22) completed pre-service orientation topics, 2 of 2 newly-hired direct care staff (#s 20 and 22) failed to complete 6 hours of pre-service dementia care training, and 2 of 2 newly-hired staff failed to complete all required training and demonstration of competency (#s 20 and 22). Residents' care needs were put at risk related to lack of training. Findings include, but are not limited to:Training records were reviewed with Staff 2 (ED Designee) and Staff 3 (Consultant) on 11/29/22. The following were identified:a. Staff 20 (CG) was hired 09/15/22, Staff 21 (Activities) hired 11/18/22, and Staff 22 (MT) hired 11/04/22. There was no documented evidence the following orientation topics were completed: * Resident rights and values of CBC care;* Abuse reporting requirements;* Standard precautions for infection control; and* Fire safety and emergency procedures. b. There was no documented evidence Staff 20 and 22 had completed pre-service dementia care training.c. There was no documented evidence Staff 20 and Staff 22 completed the required training in:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition;* Conditions which require assessment, treatment, observation, and reporting;* General food safety, serving and sanitation;* Other duties as applicable (Med pass, treatments); and* First Aid/Abdominal Thrust.Staff 20 was working independently as a caregiver without documented evidence of training in required areas, and Staff 22 was working as a medication aide and caregiver without documented evidence of required training, including competency demonstration.On 11/29/22 at 11:35 am, in an interview with Staff 2 and Staff 24 (Business Office Manager) they stated they were unable to locate any staff training records or verify the staff completed, demonstrated, or documented evidence of their 30 day competencies.At approximately 2:28 pm the survey team requested an immediate plan of correction to include:* An audit of MT employee files to determine extent of training deficiency; and* A timeframe and schedule for the completion of training and demonstrated competency in all required areas by MTs.A plan was submitted and accepted prior to survey leaving the building on 11/29/22.The plan verified Staff 23 (RN interim) completed the medication pass with the swing shift MT and night shift MT on the afternoon and evening of 11/29/22.The need to ensure the facility had a system which included documented methods to determine competency of direct care staff through evaluation, observation, or written testing was discussed with Staff 2, Staff 3, and Staff 23 on 11/29/22. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 252, C 260, C 270, C 290, C 300, and C 303.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted 1 of 1 sampled resident (#4) and others in the community. Resident 4 became combative when staff attempted to provide incontinence care and, as a result, was not toileted for greater than eight hours. Findings include, but are not limited to:Resident 4 was admitted to the facility in 04/2022 with a diagnosis of dementia.The resident's service plan, dated 04/27/22, 08/31/22 through 11/28/22 progress notes, and interim service plans were reviewed, observations were made, and interviews with staff were conducted. The following was identified:* The resident's 04/27/22 initial service plan indicated s/he was independent with toileting and had no behaviors.* Staff documented in progress notes on 13 occasions between 08/31/22 and 11/21/22 when the resident had behaviors related to the provision of incontinence care.* Interviews with staff on 11/29/22 and 11/30/22 revealed the resident frequently became agitated and combative when staff tried to change his/her brief. Staff indicated they made several attempts to provide incontinence care, and if the resident didn't allow them to provide care they would leave him/her alone and inform the next shift.In an interview on 11/29/22 at 1:19 pm on, Staff 17 (Agency Staff) reported the resident had been in the recliner in the common area since she arrived at 6:30 am. She stated she was able to change the resident's brief at 8:45 am and his/her bottom was "very, very red." She stated no one had been able to change the resident since 8:45 am.Observations between 10:32 am and 2:37 pm on 11/29/22 revealed no staff attempted to provide incontinence care to the resident. At 2:37 pm care staff were requested to change the resident's brief, as it had been nearly six hours since s/he was last changed. The caregiver stated the MT would have to give the resident a shot of morphine before she attempted to change his/her brief. The caregiver indicated it would take "about 30 minutes" for the morphine to take effect.At 3:05 pm this surveyor returned to the MCC unit, where staff stated the resident "just received" the morphine shot and it hadn't "kicked in" yet.At 3:37 pm the caregiver began asking the resident if s/he would go with her to change his/her brief. The resident refused several times. At 3:43 pm, the caregiver stated, "We'll give it a couple more tries and if he won't I'm not going to keep trying."Staff 11 (MT) was not sure if the resident had a behavior plan instructing staff what to do when s/he refused care.There was no documented evidence of a behavior plan in the resident's service plan. The facility failed to develop a behavior plan to address the resident's combative and aggressive behaviors to ensure the safety of the resident and staff during ADL care. The resident was observed to have skin breakdown on his/her buttocks.At 4:40 pm, the RN surveyor went to the MCC unit to check if the resident had received incontinence care. Three staff were able to change the resident's brief at approximately 5:30 pm. The RN surveyor reported the resident's left gluteal area was red, and there was an approximately two-inch raw, red area on the resident's coccyx which had not yet opened.At 4:30 pm, an immediate jeopardy situation was determined. Staff 2 (ED Designee), Staff 3 (Consultant), and Staff 4 (Consultant) were requested to develop a behavior plan for the resident.At approximately 7:10 pm the facility provided a behavior plan for Resident 4 and the situation was abated.The need to ensure behavior plans are developed for residents with behaviors which negatively impacted themselves and other residents in the community was discussed with Staff 2, Staff 3, and Staff 4 on 11/30/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design to not aid in elopement. Findings include, but are not limited to:A tour of the facility courtyard on 11/29/22 showed the following:Multiple metal patio chairs were easily moveable and not of sufficient weight or design to prevent potential elopement.The need for furniture that was sufficient weight and not easily moveable to prevent potential elopement discussed with Staff 2 (ED Designee) on 11/29/22. He 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 11/15/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily 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 11/15/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily 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 10/19/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily 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

Based on interview, document review and observation it was confirmed the facility is not providing personal and other laundry services to residents. Findings include but are not limited to:In separate interviews on 10/19/2022, Staff #1-5 (S1-5) stated the following: · S1-2 stated the facility has had a lot of turn over since new administration took over and with the Covid outbreak affecting residents and staff, there have been a lot of call outs. Tasks are not being done timely.· S3-5 stated resident needs are not being met when it comes to assistance with showers, toileting, laundry and housekeeping and medications are not always administered as scheduled. Document review of R1-5's service plans on 10/19/2022 revealed all five residents are service planned to receive assistance with laundry 1x per week and as needed.Document review of the facility's Universal Disclosure Statement (UDS) revealed all residents are to receive assistance with personal laundry and laundering of sheets/towels 1x weekly.During an unannounced site visit on 10/19/2022, Compliance Specialist observed the following while doing a walkthrough of all three floors:· Laundry baskets were full and clean laundry had not been put away.On 10/19/2022. findings were reviewed with and acknowledged by S1.Facility Plan of Correction:S1 reports they are actively hiring for all positions to include dedicated housekeeping staff.

Based on interview and document review it was confirmed the facility is not staffing sufficiently in number to meet the schedfuled and unscheduled needs of the residents. Findings include but are not limited to:In separate interviews on 10/19/2022, Staff #1-5 (S1-5) report the facility has had a lot of turnover since new management took over, and a lot of staff have been out sick causing shortages. S1 reports days where they are not able to meet their posted staffing plan, administration tries to fill in and Staffing Agencies are being utilized to supplement shortages. S3-5 report resident needs are not being met timely when it comes to assistance with showers, toileting, laundry and housekeeping and medications are not always administered as scheduled.Document review on 10/19/2022 of the faciity's posted staffing plan, Universal Disclosure Agreement (UDS) and staffing schedule for October confirm that the facility is not staffing to plan and was was not staffed according to plan on the date of the site visit. On 10/19/2022, findings were reviewed with and acknowledged by S1.Facility Plan of Correction:S1 reports they are actively hiring to fill administrative positions and direct care staff. They are currently using Staffing Agencies to supplement staff.

Based on interview, observation and document review, it was confirmed the facility failed to fully update their ABST. Findings include: In an interview on 10/19/22, Staff #1 (S1) stated the following:· The facility uses the DHS ABST tool. · The ABST has been updated to represent the current census of 14 residents however resident needs have not been updated to reflect changes in care needs due to staffing issues and administration turnover. · Lack of staffing, increased care needs due to illness and lack of knowledge on how to use the ABST tool has made it difficult to keep up with updating the data.Document review on 10/19/2022 of Resident #1-3's (R1-3) service plans, temporary service plans and progress notes for October revealed changes in care needs are not being input into the facility's ABST tool. R2,3 had changes in care needs within the last week as a result of Covid, S1 was unable to confirm that the increased care needs were updated in the ABST tool.During an unannounced site visit on 10/19/2022, the Compliance Specialist (CS) observed facility's ABST during document review. The dashboard is reflecting the correct census of 14 residents; however updates in resident needs have not been updated. On 10/19/2022, findings were reviewed with and acknowledged by S1.Facility Plan Of Correction:Staff #1 reports that the facility is actively hiring to fill administrative positions, and are in the process of training staff to update the tool.

Based on interview and document review it was confirmed that staff are not completing pre-service training prior to providing care. Findings include but are not limited to:In separate interviews on 10/19/2022, Staff #1-5 (S1-5) stated the following: · S1-2 stated the facility has had a lot of turnover since new administration took over and with the Covid outbreak affecting residents and staff there have been a lot of call outs. Employees responsible for training and documenting training in employee files has fallen behind.· S2 was unable to locate all employee files and stated they were not sure if all new staff had completed training prior to providing care. · S4-5 stated they did not complete all required training prior to providing care.· Due to short staffing, administrative staff were being pulled from their positions to provide care without any training at all.Document review on 10/19/2022 of S4-5 ' s employee files revealed both had not completed pre-service orientations, required trainings to include dementia training nor had competencies been verified at 30 days prior to providing care. On 10/19/2022. findings were reviewed and acknowledged by S1.Facility Plan of Correction:S1 reports they are actively hiring to fill administrative positions and direct care staff. They are working on systems to ensure all new staff are completing required trainings prior to providing care and will audit employee files to make sure all required training and documentation is included.

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 8/24/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily 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

Based on interview and record review, it was determined that the facility failed to update an acuity-based staffing tool (ABST). Findings include, but are not limited to:During an unannounced site visit on 8/24/2022, the Compliance Specialist (CS) observed the facility's ABST dashboard was not reflective of the facility's current census.In an interview on 08/24/22, Staff #1 (S1) reported that the facility is using the ODHS ABST tool however there are 2 residents that had not been admitted into the ABST at the time of the site visit. One was admitted to the facility in August and the other in June.On 08/24/2022, findings were reviewed with and acknowledged by S1.Facility Plan Of Correction:S1 and CS added the two residents to the ABST tool, corrections were made on site.

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 7/21/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily 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 7/21/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified: