Skylark Memory Care

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers for 1 of 2 sampled residents (#1) who received health services from outside service providers. Findings include, but are not limited to: Resident 1 moved into the MCC in 08/2025 with diagnoses including Alzheimer’s disease and dementia with behavioral disturbance. During the acuity interview on 03/16/26, it was reported the resident was recently admitted to hospice services. Review of the resident’s observation notes and outside provider notes from 12/16/25 through 03/16/26, identified the following: * Multiple occasions where the resident yelled at staff and other residents; * Multiple occasions where the resident called law enforcement; * Multiple resident-to-resident verbal altercations; * Emergency room visits for unmanaged behavioral expressions; * Expressions of being unhappy, wanting out of the memory care, trying to get kicked out of the memory care, and expressions of self-harm; * On 12/21/25, the primary care physician responded to the resident’s increased behaviors to “Please add Behavioral health from [company name]”; * On 02/15/26 a hospice provider note read, “PT [patient] would benefit social [sic] work evaluation for behavior.”; and * On 02/18/26 a hospice provider note read, “Wants Therapy.” There was no documented evidence the facility assisted the resident with coordinating appointments with the above outside service providers to ensure the resident’s health needs were met. The need to ensure the facility coordinated on-site health services with outside service providers was discussed with Staff 2 (Administrator), Staff 3 (Regional Director of Operations), and Staff 5 (Regional RN) on 03/18/26 at 10:18 am. They acknowledged the findings.

1. Resident #1’s record was immediately reviewed by the licensed nurse and facility management to determine unmet coordination needs related to outside health services. The facility initiated coordination with applicable outside providers, including hospice and behavioral health resources, to address the resident’s identified behavioral health and supportive service needs. 2. The facility will revise its process for coordinating on-site and off-site health services to ensure recommendations from outside providers are reviewed, acted upon, and documented timely. A standardized tracking process will be implemented for all outside provider recommendations, referrals, appointments, and follow-up services. Facility policy will be reviewed with nursing and management staff to reinforce requirements that: 1. outside provider recommendations are communicated to facility management or the nurse, 2. written documentation from outside providers is maintained in the resident record, 3. service plans are reviewed and updated timely when new interventions or services are identified, and 4. protocols are followed to coordinate needed on-site or off-site services for residents who do not independently manage their own healthcare needs. 3.On-going internal audit will be conducted for the current Memory Care residents receiving services from outside providers, including hospice, home health, behavioral health, and other supplemental healthcare services, to ensure: • Provider recommendations are documented in the resident record, • Required follow-up appointments or referrals have been coordinated, • Communication from outside providers is present in the chart, and • Service plans have been updated as applicable. Any identified concerns will be addressed promptly through record updates, coordination with providers, and service plan revisions, as appropriate. 4. The nurse or designee will audit all new outside provider notes, recommendations, and related service plan changes weekly for 4 weeks, then monthly for 2 months, and ongoing via sampling to ensure: • outside provider services and recommendations are documented, • necessary referrals and appointments are coordinated, • relevant provider information is included in the resident record, and • service plans are adjusted timely when needed.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

Based on observation, interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the MCC in 09/2025 with diagnoses including Alzheimer’s disease and malnutrition. Resident 2's current physician orders, dated 03/12/26, and MARs from 02/01/26 through 03/16/26 were reviewed, and interviews with facility staff and the outside provider were conducted. The resident was hospitalized from 03/01/26 through 03/12/26 for a urinary tract infection and dehydration. Upon discharge from the hospital, s/he was subsequently admitted to hospice on 03/12/26 due to “nearing end of life.” A hospice clinical note, dated 03/12/26, contained the following physician orders: * “Check on [Resident] every 1-2 hrs (hours)”; * “Every 2 hours alternate pillow support”; * “Keep heels elevated off of bed”; and * “[Resident] wil [sic] need to be fed. [S/he] can have a general diet if [s/he] would like, but may do best with soft foods (pudding/ice cream/mashed potatoes)”. During observations on 03/17/26 and 03/18/26, Resident 2 was noted to be lying in bed on his/her back at all times with eyes closed. Resident’s heels were not floated and were in direct contact with the sheets. No repositioning by staff was observed on 03/17/26 from 09:46 am until 1:29 pm, or at any other time during the observation, nor was pillow support alternated during this time. The resident was not offered or fed lunch on 03/17/26 or breakfast on 03/18/26. During an interview on 03/18/26 at 10:57 am, Staff 11 (MT) stated the staff offers food when the resident is awake. During an interview on 03/18/26 at 11:06 am, Staff 14 (CG) stated the resident has not been fed breakfast “because s/he is not lucid/awake yet.” Staff 14 demonstrated the assigned care tasks for Resident 2 in care coordination software but acknowledged the tasks had not been updated since the resident returned from the hospital. Staff 14 stated the resident became bed-bound after hospital discharge. The tasks were updated on 03/18/26 during the survey. On 03/18/26 at 11:37 am, Staff 14 was observed providing Resident 2 with a protein shake, of which the resident consumed about 90%. Resident 2 appeared to be awake and easily aroused when prompted by care staff. On 03/18/26 at 2:54 pm, Staff 12 (MT) stated Resident 2 “has not eaten much lately, had one hamburger in eleven days while in hospital. Hospital could not get [him/her] to eat. Usually, caregivers offer food or drinks.” The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 2 (Administrator) and Staff 3 (Regional Director of Operations) on 03/19/26 at 9:49 am. They acknowledged the findings. 2. Resident 1 moved into the MCC in 08/2025 with diagnoses including Alzheimer’s disease, dysphasia, and esophageal obstruction. Review of the resident’s signed physician orders, dated 01/11/26, and the 02/01/26 through 03/16/26 MARs identified the following: * The resident was prescribed omeprazole 20 mg delayed release tablet, give one tablet daily. The 02/01/26 through 03/16/26 MARs showed the resident was administered one 20 mg capsule every other day. The facility failed to carry out the omeprazole 20 mg order, as prescribed, for 25 doses between 02/01/26 and 03/16/26. The need to ensure physician orders were carried out as prescribed was discussed with Staff 2 (Administrator), Staff 3 (Regional Director of Operations), and Staff 5 (Regional RN) on 03/18/26 at 10:18 am. They acknowledged the findings.

1.Upon identification of the concern, the Administrator and licensed nurse collaborated to complete an immediate review of care and medication practices for Residents #1 and #2. For Resident #2, hospice orders were reviewed in full, and care staff were re-educated on required interventions, including repositioning, heel elevation, routine checks, and feeding support. The resident’s care plan and task list in the care coordination system were updated to reflect current physician and hospice orders. Staff began implementing interventions as prescribed, including repositioning schedules and nutritional support. For Resident #1, the medication administration record (MAR) and physician orders were reconciled. The discrepancy related to omeprazole administration was corrected, and staff were re-educated on ensuring medications are administered exactly as prescribed. Ongoing monitoring was initiated to ensure compliance. 2. The facility will strengthen processes to ensure all medication and treatment orders are accurately transcribed, updated, and carried out as prescribed. This includes: • Implementing a standardized process for reviewing and updating care tasks and MARs following hospital discharge, hospice admission, or any change in condition • Ensuring all written and signed physician or practitioner orders are promptly entered into the resident record and care systems • Reinforcing that only licensed practitioners may change orders, and staff must not alter administration practices without a documented order • Providing focused education to care staff and medication technicians on following orders as written, including hospice-specific care needs and feeding expectations 3. An audit will be conducted for Memory Care residents with active medication and treatment orders, including those receiving hospice or other outside services, to ensure: • Medication administration records match current physician or practitioner orders • Treatment and care tasks reflect current orders and resident condition • Orders related to repositioning, nutrition, and specialized care are being carried out as prescribed • Documentation supports that care and medications are administered according to orders Any identified discrepancies will be corrected promptly through order clarification, record updates, and staff re-education. 4.The nurse and program manager/Director will be responsible for overseeing the corrections, completing the audit, and ensuring medication and treatment orders are carried out as prescribed. The nurse or designee will complete: • Weekly audits of MARs, treatment records, and care tasks for 4 weeks • Monthly audits for 2 additional months, and as needed or indicated by review. Audits will ensure: • Orders are accurately transcribed and current • Medications are administered as prescribed • Treatment interventions are completed and documented appropriately.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) data was updated no less than quarterly, at the same time the resident's service plan was updated, for 12 unsampled residents whose ABST evaluations were reviewed. Findings include, but are not limited to: The facility’s ABST was reviewed on 03/16/26 at 3:26 pm. The following was identified: ABST data for 12 of 26 residents was not updated at least quarterly, at the same time the resident's service plan was updated. The need to ensure residents’ ABST data was updated no less than quarterly, at the time of their quarterly service plan update, was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 03/17/26 at 9:30 am. They acknowledged the findings

1.-The ABST shall be completed prior to resident admission, updated promptly following any significant change in the resident’s condition, and reviewed no less than quarterly in alignment with scheduled service plan updates to ensure ongoing accuracy. 2.-The facility will implement the following system improvements: • Establish a centralized tracking system (electronic or manual) to monitor ABST due dates, including admission, significant change, and quarterly reviews • Develop a standardized workflow aligning ABST updates with service plan reviews • Provide staff re-education and training on ABST requirements and timelines • Assign designated responsibility (e.g., Administrator or Nurse) for oversight and compliance monitoring • Implement routine monthly audits to ensure ongoing adherence 3.- The Administrator or designee will conduct the following audits: • Monthly audits for three (3) months of: - ABST completion and update timeliness - Alignment between ABST data and posted staffing plan - Verification that staffing levels meet or exceed the posted plan 24 hours per day, seven (7) days per week - Audit findings will be documented and reviewed with the leadership team. Any identified concerns will result in immediate corrective action, including re-education or process adjustments. - After the initial monitoring period, compliance will be maintained through ongoing quarterly reviews aligned with service plan updates. 4.-The Administrator will maintain primary responsibility for ensuring completion of all corrective actions and sustained compliance. The Nurse will assist with day-to-day oversight, including monitoring ABST completion, conducting audits, and reporting findings to the Administrator for review and follow-up

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

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

Based on 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 363.

Please Refer back to C363

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

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

Please refer back to C290 and C303

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

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

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

FACILITY MAIN KITCHEN -POC 1. The following items have been completed or are in process Violation 1 - a) Cleaned the countertop spills, juice machine splatters, cleaned brown residue from the wall next to the coffee maker, removed fans from the kitchen. b) Repair cabinet under the sink in the dining room. Violation 2 - (a)-Juice machine splatters cleaned. -Removed fans from the dining room. -Deep fryer grease scheduled to be deep cleaned 3rd party commercial cleaning company. -Three-compartment sink pans washed and put away. -Cleaned paper towel dispenser. -Cleaned stains from the handwashing sink. -Hired 3rd party commercial cleaning company to clean the handwashing sink, pre-clean station, dishwasher area, and three compartment sink of food debris and grease build up. -Hired 3rd party company to clean the vents throughout the kitchen and two door refrigerator dust accumulation. -Hired 3rd party company to clean the spills and grease from ceiling throughout the kitchen and around the dishwasher/oven area. -Removed ice from inside the one-door freezer with built up ice. -Rack used for storing clean utensils replaced and accumulated dust removed. -Hired 3rd party cleaning company to clean the black residue inside of the commercial can opener. -Removed the large ice build-up on the floor in the walk-in freezer. -Cleaned black residue from janitor's closet floor and walls. -Cleaned spiderwebs and rust from sprinkler heads. -Hired 3rd party company to clean the heavy grease build-up on the front, side, and back of the oven and grills. -Hired 3rd party to clean the floor and baseboards around the dishwasher area. -Cleaned the black residue from the drains throughout the kitchen. -Cleaned the dust on the side and rear piping area of the ice machine. -Cleaned the brown residue from the steamer. (b) -repaired the top panel of the freezer. -Replaced the soup warmer. Violation 3- -Disposed of all items without a date. -Removed the scoop from the brown sugar. -Disposed of the food items including cereal bags without a date. -Disposed of the food items in the freezer without a date. -Disposed of the food items in the two door refrigerator without a date. -Disposed of the food items in the walk in cooler without a date. -Disposed of the tomatoes. Violation 4 - -Silverware will be wrapped or provided upon food service. -Lids put onto all trash cans in the kitchen and dining room. -Kitchen staff were educated on not placing their thumbs inside clean cups and bowls. -Kitchen staff provided hair nets and educated on restraining hair. -Kitchen staff educated on changing gloves between dirty and clean tasks. -Kitchens staff educated on cleaning thermometers after each use. 2. (a) A revised routine cleaning schedule that includes by shift, daily, weekly, monthly, and quarterly cleaning tasks. This was implemented immediately (b) Provided education to the kitchen staff on use of the task sheets, food sanitation rules, and food storage. Will continue to provide education to staff as needed. 3. Daily, weekly, monthly, and quarterly kitchen audits and monitoring will be performed by leadership team. 4. Dining Services Director, Business Office Manager, Memory Care Director, and Executive Director will oversee to ensure corrections are completed and assist with ongoing monitoring of the program.

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

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

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to: Refer to C240

1. The following actions have been taken or are in process Cottage 1 & 2 • All undated food items were discarded. • Cabinets were emptied, cleaned, and sanitized. • Brown residue below the juice dispenser was removed and the area sanitized. • Juice dispenser was thoroughly cleaned, sticky residue removed and sanitized. • Baseboard next to the juice dispenser was inspected and repaired to address water damage.Water damaged cupboard will be repaired and sealed to avoid further deterioration. 2. a. A revised cleaning checklist by shift daily to include cleaning of the juice dispensors, cabinets, etc was implemented. b. Daily walk through of kitchette areas in both Cottages will be completed by administrator or designee to spot check for cleanliness and food labeling. c. Staff training was completed with all staff to include proper food labeling, sealing, storing and sanitation procedures. 3. • Daily walk throughs will be conducted by adminstrator to ensure cleanliness and proper storage of food items. Weekly inspections of cabinets and food storage areas will now be conducted by the Dietary Supervisor. • Maintenance staff will inspect baseboards monthly for signs of damage or moisture. 4. The Memory Care Administrator and Executive Director will be responsible for all corrections and monitoring to ensure compliance

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

Based on observation and interview, it was determined the facility failed to 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.

The plan of correction for the kitchenettes on memory care are to have maintenance paint the doors leading into the kitchenettes in both cottages and the cupboards. Staff will clean the drawers, cupboards, and inside of the fridges and freezers. They have been given task list with these items and both the dietary manager and memory care program director will follow up monthly to ensure these areas are clean and in good repair.  Staff will be inserviced on this in the staff meeting on 8/15/24 The following areas will be repaired by maintenance 1. enterance and exit doors 2. gouge in wall by reach in freezer 3. wall behind the handwashing sink 4. faucet in the dink washing area 5. chipped paint on walls throughout kitchen 6. ceiling panels 7. Doors in Memory care The kitchen will be cleaned and to ensure this is maintained new staff task list will be presented and all staff will be trained on these on 8/15/24 Staff will also be retrained on proper food storage on 8/15/24 Garbage cans will have lids on them moving forward and will be placed on the task list for cleaning daily Audits will be done by the dietary manager of the kitchen weekly to ensure task list are done and we are in compliance with food safety and sanitation guidelines, once we are in compliance they will be done monthly

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.

See 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 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.

1. The required postings for for administrator or designee and staffing are posted. 2. Administrator or designee will do daily walkthroughs to ensure postings are current. 3. Daily for one month and then move to weekly audits, and when the ABST is updated. 4. Admnistrator and MC Program Director.

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.

Refer to C231, C252, C260, C270, C280, C290, and C303 related to resident records and documentation.

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.

1. Residents 2, 4 will be assessed and service plan updated as determined. All residents will be assessed and their service plans updated. Resident rights training will be provided to all staff. All staff will be trained again on abuse and neglect reporting. Management staff will be trained on investigation, reporting, and documentation. All sharp rocks or other potentially hazardous materials on the ground that could cause have been removed. All staff training on abuse and neglect reporting and resident rights scheduled for December 29, 2022. 2. Review incident reports within 24 hours of incident occurance. Incidents and concerns will be reviewed in the clinical meeting. Regular maintenance walkthroughs of the courtyard. 3. With each incident. Weekly property inspections for three months and then monthly. 4. Administrator or designee, RN, maintenance director, operations consulting team.

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.

1. A full time activity director will be hired. Activity calendar is in place and posted. Staff are being trained in how to engage in activities. 2. The new activity director will be trained in how to develop and deliver activities in memory care. Carestaff will be trained in how to engage in activities listed on the calendar and on each resident's individual activity plan. The RCC will monitor activity delivery. 3. Daily and weekly. 4. Administrator/designee, MC program director, activity director (when hired).

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.

1. Resident 1, 2 and 4 evaluations have been updated. All residents evaluations will be reviewed and updated. The ABST will be updated as determined by the updated evaluations. 2. A new evaluation form will be implemented that includes all required elements. Once all evaluations are updated, an evalation schedule will be developed and implemented to correspond with the service plan. 3. Weekly and monthly. 4. Administrator, designee.

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.

1. Resident 2 and 4 service plans have been updated to reflect current needs. ABST will be updated. All resident sevice plans will be reviewed and updated. Service plans will be available to staff at all times. Staff will be trained on how to read and follow the service plan. 2. The evaluation data will be used to develop the service plan. A service plan schedule will be developed and implemented. Adherence to the service plan schedule will be reviewed weekly. New service plans will be reviewed by all staff. 3. Weekly and monthly. 4. Administrator, designee.

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.

1. Resident 2 and 4 will be assessed by the RN including historical review to identify risks. Any changes of condition identified will be noted on a TSP and staff will be notified of interventions and monitoring. 2. The 24-hour book will be reviewed, redeveloped and implemented with staff training. Staff will be taught to read and follow a TSP and to notify the RN when required. Med techs will be taught how to document. Clinical meeting will occur multiple times per week and changes of condition and documentation will be reviewed. Licensed nurses will be trained in assessment, interventions, and follow up of change of condition and monitoring. All direct care staff will be trained on change of condition. 3. Daily and weekly. 4. Administrator, designee, licensed nurses.

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.

1. Resident 1, 2 and 4 will be assessed to ensure updated status information is provided to outside service providers. 2. A new process in place for where outside services can obtain the outside service form and what to do with it when it is complete. There is a new outside provider binder with sign in sheet and blank forms. The completed form will go to the med tech and will be processed similar to a new order, using the 24-hour book system. Med techs and licensed nurses will be trained on how to review, process, and document outside provider communication. Outside provider communication and follow up documentation will be reviewed in clinical meeting. TSP will be implemented and service plan updated as needed. 3. Daily and weekly. 4. Administrator, designee, and licensed nurses.

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.

1. Pharmacy contacted for every order including VA residents. Training for all med techs on December 7-8, 2022. Self-med evaluation audit complete for all residents. Full controlled substance to MAR audit will be done. 2. System review and correction to prevent future concerns with Consonus Pharmacy on December 27-28, 2022 (3-way audit). Exception and variances reports are reviewed multiple times per week. Order recaps will be reviewed and sent for signature. Training for all med techs on medication system needs. Clinical meetings held multiple times per week to review medication exceptions and variances. A competency checklist will be implemented and all med tech skill compentency will reviewed and training will be developed to address competency needs. New med techs will be trained and competency before being independently assigned medication related job duties. RN will assess competence for all med techs related to RN delegation and complete documentation. 3. Daily, monthly and quarterly. 4. Administrator, designee, RN.

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.

1. Resident 2 and 4 treatment orders are in place. 2. All resident orders have been reviewed by the pharmacy and sent to prescribers for review and signature. An audit will be done by Consonus Pharmacy on December 27-28, 2022 to reconcile orders. A new system will be implemented to review orders and send to prescribers at quarterly service plan updates. 3. Monthly and quarterly. 4. Administrator, designee, RN.

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.

1. The ABST is being updated as evaluations and service plans are updated, and with any change of condition. 2. Same as above. Staffing will be scheduled based on ABST information. 3. With any change of condition and quarterly. 4. Administrator, designee.

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.

1. All staff with missing documentation for abdominal thrust will be trained and redemonstration observed by RN. 2. All staff training records will be reviewed for completeness and staff will be assigned training. Training packets will include all required assigned training on Relias for preservice and 30 day training. All staff will complete CPR training in January 2023 to include abdominal thrust. A training checklist will be developed to go into each employee file. 3. Monthly. 4. Administrator, designee.

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.

1. Consultant will provide facility with new fire drill form to include all required elements. Fire drill is planned for December 2022. 2. Training will be provided to maintenance director on how to run and document a fire drill. A schedule of fire drills and alternating fire and life safety topics will be developed. 3. Monthly. 4. Administrator, designee, maintenance director.

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.

1. Consultant will provide a form for resident fire and life safety instruction to be part of the admission packet. All residents will be provided fire and life safety information and documentation completed. 2. Fire and life training instructions will be included in the admission packet. Staff engaged in the admission process will be trained on how to provide instruction. Completed admission packets will be audited after each move in. A checklist will be developed to go with every resident move in for process elements. 3. At each admission and annually. 4. Administrator, designee.

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.

1. All toxic materials are securely stored. Staff have been trained that laundry closets must be locked. 2. Staff will be trained on hire regarding chemical storage and securing laundry areas. Daily administrative walkthroughs to ensure laundry areas are secured. 3. Daily. 4. Administrator, designee.

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.

1. Microwave and refrigerator were cleaned. Wall under kitchen counter cleaned. The transition strip has been ordered and will be replaced. The linoleum in the laundry room has been ordered and will be replaced. The exit door to the patio will be repaired and repainted. 2. A cleaning checklist will be developed and implemented for the kitchenette. Staff will be trained on how to clean the kitchenette. Maintenance will do regular walk throughs to identify any environmental concerns. 3. Weekly. 4. Administrator, designee, maintenance director.

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.

Refer to C300 and C165.

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.

Refer to C152, C155, C231, C242, C361, C372, C420, C422, C510, and C513.

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.

1. The training plan is being reviewed and updated to adhere to regulatory requirements. Staff training files are being audited for preservice training and competency completion. Consultant will provide a list of training from Relias that meets requirements. Staff will be assigned training to complete. 2. All staff training records will be reviewed for completeness and staff will be assigned training. Training packets will include all required assigned training on Relias for preservice. A training checklist will be developed to go into each employee file. 3. Monthly. 4. Administrator, designee.

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.

Refer to C252, C260, C270, C300, and C303.

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.

1. Resident 4's evaluation and service plan has been updated. Consultant gero psych specialist was onsite to complete assessment with follow up written report. Consultant gero psych specialist also assessed two other residents with follow up written report. 2. All residents will be reviewed for need for behavioral assessment. Staff will be trained by consultant in recognizing and responding to behaviors as communication, responding to ADL needs, and change of condition. TSPs will be used to document changes. Documentation and concerns will be reviewed in clinical meeting. Behavioral plans will be developed for all residents with behavioral needs. 3. Daily, weekly, monthly. 4. Adminstrator, designee, licensed nurse.

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.

1. The metal patio chairs were removed and weighted furniture or furniture that can be secured will be ordered. 2. Regular walkthroughs of courtyard area to ensure compliance. 3. Weekly. 4. Administrator, designee, maintanence director.

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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day Situations 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; and OAR 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.

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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

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 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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

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 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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

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:

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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day