Brookdale Salem

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the re-licensure survey, conducted 08/28/23 through 08/31/23, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective, as evidenced by failure to monitor residents in common areas who had documented altercations and behaviors were frequently observed, failure to provide residents with ADLs, lack of activities, failure to provide meal assistance to dependent residents, unsanitary environmental conditions, and residents unable to access rooms including bathrooms. 1. A situation was identified which constituted an immediate threat to residents' health and safety in the following areas: * OAR 411-054-0025 (1) Facility Administration: Operation * OAR 411-054-0025 (4) Reasonable Precautions * OAR 411-054-0027 (1) Resident Rights The facility put immediate plans of correction in place during the survey, and the situations were abated. 2. Refer to deficiencies in the report.

The facility put immediate plans of correction in place during survey, and the situations were abated. Executive Director enrolled in Leading Age OR ALF Administrator Course.  Required coursework and competency testing to be completed by 9/30/2023. District team will make twice weekly visits to provide oversight for the next 30 days, weekly visits for another 30 days, and then monthly visits thereafter as part of ongoing monitoring and support The Executive Director and District team is responsible for this plan of correction.

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. This is a repeat citation. Findings include, but are not limited to: During the revisit to the re-licensure survey, conducted 01/22/24 through 01/24/24, administrative oversight to ensure adequate resident care and services in the facility was found to be ineffective, as evidenced by failure to monitor residents in common areas who had documented altercations and behaviors, a lack of activities throughout the day in the neighborhoods, severe and pervasive urine odors throughout the facility and residents unable to access rooms including bathrooms. A situation was identified which constituted an immediate threat to residents' health and safety in the following areas: * OAR 411-054-0025 (4) Reasonable Precautions The facility put an immediate plan of correction in place during the survey, and the situation was abated. Refer to deficiencies in the report.

1.The facility put immediate plans of correction in place during survey, and the situations were abated. 2. District team members and/or Brookdale clinical or dementia care specialists will connect with the community team a minimum of twice weekly via in person visits, training/support calls, and/or remote documentation review. This additional monitoring will continue for the next 30 days, then move to weekly for the following 30 days, and then monthly for the next 30 days. 3. Facility has entered into an agreement with a department-approved Registered Nurse Consultant whose first visit will be on or before February 26, 2024.

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors and available for inspection. Findings include, but are not limited to: Tours of the facility were conducted between 08/28/23 and 08/30/23 and revealed a copy of the most recent re-licensure survey, including all re-visits and plans of correction, was unable to be located for viewing. On 08/30/23, at approximately 11:30 am, Staff 1 (ED) reported locating the survey binder. She indicated the binder would be placed in the entrance foyer. On 08/30/23, the need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (ED). She acknowledged the findings.

During survey visit, the prior re-licensure survey was located and placed in the entrance foyer. The front desk associate was educated on September 22, 2023 on the importance of regularly verifying that the re-licensure survey is present and available for residents and guests. The front desk associate will confirm that the re-licensure survey is present at the beginning and end of each shift a minimum of 3 days weekly. The Executive Director or designee will assure that the correction is completed.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of 1 of 1 sampled resident (# 9) who was dependent on staff and experienced a choking/aspiration episode while eating. This placed the resident at risk and constituted an immediate threat to the resident's health and safety. Findings include, but are not limited to: Resident 9 was admitted to the facility in 2014 with diagnoses including pneumonia, dysphagia (difficulty swallowing), and dementia. Resident 9's clinical record, including physician orders, service plan, incident reports, outside provider communication, and progress notes, was reviewed and the following was noted: * A physician order dated 08/23/22 noted the resident's diet was changed to pureed, extra sauces, butters, and gravies added to food, and regular liquids. * A progress note dated 07/29/23 revealed the resident had a choking/aspiration episode when provided with Jello and "started to turn purple..Med Tech was called and provided the Heimlich maneuver as soon as I got there and resident had gotten color back...Resident was aspirating for approximately 10 minutes after the occurrence. This was witness [sic] by a caregiver and she she said at 10:00 [am] snack [resident] started to cough, turn colors in [his/her face], was showing signs of having a hard time breathing." * An incident report dated 08/07/23, nine days after the aspiration episode, noted "Resident received a puree diet with thickened liquids. This event was a one time event. [S/he] was not injured and was able to continue eating without incident. Abuse/neglect are not suspected." * On 8/25/23, a speech pathologist assessed the resident for dysphagia and provided interventions for staff to follow. The resident required assistance to feed himself/herself and could tolerate puree with nectar thick liquids with a pause between bites and sips. It was noted the resident "coughed up green mucous and has been running a low grade fever." * The current service plan was not reflective of the ST recommendations, including positioning for the resident during meal times. During a lunch meal observation on 08/28/23, the resident was observed to be in a wheelchair with his/her head tipped back. The resident was served a puree diet with nectar thick liquids. A caregiver stood by the resident, placed the resident's spoon in his/her hand, and walked away. The resident was falling asleep and was not able to consume the meal on his/her own. The caregiver offered the resident one spoonful of food; the resident was asleep and did not take the bite. The caregiver stated, "I am not going to feed [the resident], as [s/he] continues to fall asleep." On 08/29/23 at 8:30 am, the resident was observed in the dining room at breakfast. S/he was in his/her wheelchair with his/her head leaning back and to his/her left. A caregiver spoke the resident's name repeatedly in an attempt to wake him/her up and asked if s/he wanted to have breakfast. The caregiver attempted to get resident to hold his/her spoon, saying, "I need you to hold your spoon so you can eat"; "[Resident], I need you to eat"; and "Are you going to eat?" The resident did not respond, and the caregiver put the spoon back in the bowl of hot cereal. The resident remained in his/her wheelchair at the dining room table until 9:25 am, at which time the caregiver gave the resident a bite of his/her cereal. The resident was speaking in "word salad" and began coughing. The caregiver told him/her to not talk while s/he was eating so s/he didn't choke. The resident continued to cough, and the caregiver gave him/her a drink of thickened water. Resident 9 had a choking/aspirating experience without an immediate evaluation or a plan put in place to avoid or minimize additional occurrences. Staff were not educated on proper meal assistance nor provided guidance on thickened liquids (Jello is not a thickened liquid). There was no documented evidence the resident was monitored after administration of the Heimlich and the current service plan lacked the meal assistance recommendations from the speech pathologist. There was no documented evidence the resident was evaluated related to the green mucous and fever. The situation constituted a condition which could threaten the health, safety, or welfare of the resident. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 (ED), Staff 4 (Regional Director of Operations), and Staff 17 (Lead MT/Resident Care Manager) on 08/29/23. An immediate plan of correction was requested by the survey team and was received on 08/29/23 at 4:45 pm. The situation was abated.

Resident 9: Service plan has been updated to reflect the need for the resident to be sitting upright and     her head not tilted back while eating.  The service plan was also changed to thickened liquids and to follow the recommendations provided by Speech Therapy.  On 8/30/2023 staff received training on the community policy for "Thickened Liquids and Regular Diet Guidelines".   Our carpet cleaning vendor was out on 8/30/23 and cleaned the common area carpets.  The floors in the resident rooms were cleaned by the community maintenance team. An audit was completed of Brookdale's choking hazard course.  Any associate identified to have not completed the course completed on or before 9/5/23.  An audit was completed on residents to verify their dining skills ability forms were up to date. These forms were reviewed and updated as needed by community nurse on or before 9/5. Area Health and Wellness Director (RN), and Health and Wellness Director (LPN) completed Leading Age Role of the Nurse on 9/12-9/14/23. Community leadership and associates were re-educated on 9/1/23  on the shift to shift communication and report policy. On 9/7/2023, care staff received training in cueing and assisting residents with feeding during meals.  On 9/21/23, the Health and Wellness Director provided additional training to staff on identifying dining difficulties in residents such as coughing vs choking and the necessary support to provide. Outside vendor will continue to provide carpet cleaning on a monthly basis both spot cleaning as well as alternating through all common areas. A member of management or designee will be present in the dining room for meals 3 times a day, 5 days a week for the next 30 days and then 2 meals, 5 days a week thereafter as part of standard dining support. The Executive Director or designee is responsible for this plan of correction.

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Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of sampled and unsampled residents throughout the facility due to the actions of 1 of 1 sampled resident (#15) who had unaddressed agitation and aggression toward multiple residents, staff and visitors. Multiple sampled and unsampled residents were hit or punched by Resident 15 which constituted a threat to their health and safety. This is a repeat citation. Findings include, but are not limited to: Resident 15 was admitted to the facility in 11/2022 with diagnoses including Alzheimer's disease. Resident 15's clinical record, including physician orders, service plan, temporary service plans (TSPs), incident reports, APS reports, outside provider communication and progress notes, was reviewed and the following was noted: * On 01/09/24, Resident 15 punched Resident 1, located in the Clare neighborhood, and hit an unsampled resident, located in the Bridge neighborhood. Resident 15 also hit multiple care staff and an unsampled resident's family member. Staff called 911, and the resident was taken to the emergency room (ER). A TSP noted that if resident was showing signs and symptoms of agitation, staff should redirect the resident, remove others, and call 911. * On 01/10/24, the resident returned to the facility from the emergency room. A TSP was put in place which stated staff should continue to redirect and reassure resident when showing signs of agitation. There was no documented evidence the resident was evaluated for the ability to return to the facility and engage safely with other residents. *On 01/11/24, staff documented continued behaviors from Resident 15, including verbal aggression towards staff and attempting to elope. A TSP was put in place which instructed staff to "Offer 1:1, offer reassurance, listen and use validation." * On 01/12/24, Resident 15 demonstrated increasing levels of agitation and punched Resident 13 and slapped a caregiver. Resident 15 also attempted to hit an unsampled resident and had a verbal altercation with an additional unsampled resident. The resident's roommate reported feeling "very scared and was afraid of her and didn't want to be in the same room." Staff called 911, and the resident was taken to the ER. The TSP put in place did not include any new interventions or instructions to staff. There was no documented evidence that the resident was evaluated and resident specific interventions put in place to assure the safety of the other residents in the building upon return from the ER. * On 01/16/24, Resident 15 attempted to hit two unsampled residents and a caregiver. Staff intervened before physical contact was made. The TSP put in place did not include any new interventions or instructions to staff, and repeated the same interventions from 01/11/24 and 01/12/24, "Offer 1:1, offer reassurance, listen and use validation." There was no documented evidence an evaluation of the residents condition and continued agitation and aggression was completed. * On 01/20/24, Resident 15 was documented to be agitated, have unsteady gait, and slurred speech. S/he "swat and hit" an unsampled resident, as well as a caregiver and facility visitor. The resident was again sent to the ER and returned later that same evening. The TSP instructed care staff to "redirect [resident] to a quiet place" and report any concerns to a MT. There was no documented evidence an evaluation was completed, or interventions put in place to assure the safety of other residents in the building. Over the course of an 11 day period, from 01/09/24 through 01/20/24, Resident 15 punched and hit at least four residents including two sampled residents (#s 1 and 13) and two unsampled residents who were located in both neighborhoods of the facility, attempted to hit at least two unsampled residents, multiple caregivers and multiple resident's visitors and/or family members, and showed verbal aggression or threats toward multiple unsampled residents. There was no documented evidence of an evaluation/assessment or resident specific interventions put in place to address the Resident 15's escalating aggressive behavior. Resident 15 continued to physically abuse and have verbal altercations with  residents through out both neighborhoods of the facility as well as visitors and staff. The situation constituted a condition which could threaten the health, safety, or welfare of all residents in the facility. An immediate plan of correction was requested by the survey team and was received on 01/24/24 at 3:30 pm. Interventions put in place included providing the resident with an individual caregiver to provide one on one care and supervision until the resident could be more fully assessed and additional interventions put in place. The immediate jeopardy situation was abated. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 (ED), Staff 2 (Area Nurse Manager), Staff 34 (Health & Wellness Coordinator/LPN) and Staff 39 (Area Health & Wellness Director/RN) on 01/24/24. They acknowledged the findings. 2. Based on observation, interview and record review, it was determined the facility failed to ensure reasonable precautions were taken to ensure residents health and safety related to modified diet textures and supervision in common areas. This is a repeat citation. Findings include, but are not limited to: A. Observation of meals, interviews with staff, and review of the Brookdale Diet Manual identified the following: * Between 01/04/24 and 01/16/24 Resident 14 had a signed order for a Mechanical Soft diet. Staff 1 (ED) and Staff 34 (Health & Wellness Director/LPN) confirmed on 01/23/24 that Resident 14 received a Texture Modified diet during that period, and that Mechanical Soft diet orders were interpreted by the facility as Texture Modified diet orders, a Brookdale approved therapeutic diet. * The facility Diet Type Report dated 1/22/24 documented 10 residents with a Texture Modified diet order. Staff 34 reported that a Texture Modified diet is defined in the Brookdale Dietary Manual. After reviewing the Brookdale Dietary Manual, it was determined that during the survey residents with a Texture Modified diet order received multiple foods outside of this therapeutic diet for swallowing safety including watermelon, raisins, peanut butter, and the following raw vegetables: tomatoes, onion, broccoli, and carrots. The need to clarify therapeutic diet orders with the ordering practitioner, as well as ensure residents received the appropriate therapeutic diet, was discussed with Staff 1 (ED), Staff 34 (Health & Wellness Director/LPN), and Staff 2 (Area Nurse Manager) on 01/24/24. They acknowledged the findings. B. During the survey dates of 01/22/24 through 01/24/24, the Clare and Bridge neighborhoods were observed to have residents unattended for periods of up to 15 minutes. Residents were observed to search for staff, pacing, crying out for help, asking for help with toileting needs and entering multiple apartments, but staff could not be located. On 01/22/24, between 1:35 pm and 2:10 pm, the following was observed: *An unsampled resident was observed opening each door along a hallway, stating "Which one of these is mine?" S/he stated s/he was very scared s/he could not find his/her room and worried someone might be in it. S/he was not able to find care staff to assist her for greater than 10 minutes. *An unsampled male resident was seen entering multiple closed resident's rooms. When he entered Resident 13's room, the resident stated "stop coming in here." The unsampled resident continued entering rooms until care staff arrived over 10 minutes later. *An unsampled female resident was heard yelling for help in her room. No care staff were in the hallway or area, and did not attend to her until the surveyor went to find care staff to help after 10 minutes. On 01/24/24 between 9:00 am and 9:30 am, the following was observed: *10 residents were seated without a caregiver present for greater than 15 minutes in the Bridge neighborhood television room. *Two residents were visibly soiled. *A resident walked down the hallway from the television room to the hallway bathroom, which was locked. The resident appeared soiled, and began whimpering and crying out for help. The resident continued to cry and walk down the hall for 10 minutes before a caregiver came into the television room and sat down. This surveyor had to call the caregiver's attention to the resident and request that they assist him/her. *Resident 15, who had a history of verbal and physical altercations with multiple other residents, was observed pacing the hallway and going in and out of four other resident's rooms whose doors were closed. This continued for 13 minutes before care staff entered the area. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 (ED), Staff 2 (Area Nurse Manager), Staff 34 (Health & Wellness Coordinator/LPN) and Staff 39 (Area Health & Wellness Director/RN) on 01/24/24. They acknowledged the findings.

1. One on one supervision was immediately implemented for resident 15. A behavioral consultant is involved to support the resident, family, and physician. DHS case managers are involved to assist with interventions. Alternate placement has been secured following a DHS assessment for need. Management of Behavior Challenges training was immediately completed by the Executive Director, Area Health and Wellness Director and Health and Wellness Director. Community Leadership (Executive Director, Clare Bridge Program Coordinator, Area Health and Wellness Director, Health and Wellness Director) also completed Behavioral Expressions training on 1/25/24. This course was taught by Brookdale's Divisional Dementia Care Specialist and this curriculum included participants learning: 1.communication with physicians, families and fellow associates in a way that encourages them to support replacing antipsychotic medications with healthier, more effective interventions. 2.how to personalize each resident's service assessment and service plan so that they can be used to provide person-centered care which targets the domains of well-being and prevents some behavioral expressions from occurring. 3. to develop and support individual and/or group programming that is effective in preventing unwanted behavioral expressions. 4. to proceed through the problem-solving process with all relevant associates to plan effective interventions and prevention of unwanted behavioral expressions. 5. to explore how to consistently communicate with care associates to persuade them to use effective interventions that prevent unwanted behavioral expressions. 6. effective ways to partner more fully and to use the tools designed to make their relationship more collaborative and effective. The therapeutic diet for Resident 14 was clarified during survey. Clarification for other residents with a modified texture diet order has been received from the residents' personal physicians. Dining service manager was provided education during survey of approved foods and menu items for therapeutic diets. Additional support and education was provided by Brookdale dining specialist team on January 30, 2024. This training included overview of therapeutic diets and approved foods.  Dining Service Manager then provided this training to facility staff.  This training was followed up by a visit from local dining mentor on February 4, 2024 to validate understanding by all dining associates. 2. Incident reports from the last 60 days have been reviewed to identify any residents with a history or pattern of behavior. The included ensuring proper investigation and interventions are in place and reported as needed. Staff to receive education on managing challenging behaviors and behavioral problem solving on or before February 23, 2024. A schedule was created for staff presence in all areas where residents are present. 3. Incidents will be reviewed during clinical meeting 3-5 days a week to assure that proper interventions are in place and to evaluate their success. Collaborative care meeting occurs twice monthly.  Executive Director, Health and Wellness Director or designee will complete community walk-through. RN Consultant will be scheduled to be in the community to provide oversight as per condition and community will implement any training and/or recommendations. Community leadership will be attending a meal a minimun of twice daily 5 times per week to ensure residents are receiving proper theraputic diets. 4. Executive Director, Health and Wellness Director are responsible for this plan of correction

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were treated with dignity and respect and had a safe and home-like environment. Residents' lacked dignity and respect and their environment was not homelike and safe. Findings include, but are not limited to: During the survey on 08/28/23 through 08/29/23, the following was observed: * The facility had pervasive urine odors, corners throughout the facility were saturated with urine, there were dark stains on the furniture, and there were dark stains and fecal matter on the carpet throughout. * Residents' rooms were locked, and residents did not have access to the common area toilets. There were multiple observations of ambulatory residents trying to find a place to go to the bathroom. * Multiple sampled and non-sampled residents appeared disheveled and had not been showered for an extended period. Residents' hair was uncombed, greasy and/or unclean. Residents observed had body odor and/or urine odor, as well as soiled or stained clothing. Several residents clothing had dried food debris on pants and/or shirts. Resident fingernails were unkempt with dried brown/black substances underneath the end of their nails, and wheelchairs had dried-on food matter, dust, and debris on them. In an interview with Staff 23 (CG/MT) on 08/28/23, she stated the residents were not showered the week of 08/14/23 through 08/18/23 and "very few" residents got showered the week of 08/21/23 through 08/25/23, related to being "short-staffed." She stated for one month, she had 28 residents to attend to as a caregiver with "no support from management," and her last day working at the facility was 08/28/23. Staff 23 further stated residents' wheelchairs had not been cleaned for a while because there was "no time" to clean them. This represented a situation which placed residents in an unsafe environment and required an immediate plan of correction. On 08/29/23 at 1:30 pm the facility provided an immediate plan of correction and the situation was abated. The need to ensure residents were treated with dignity and respect, and had a safe and home-like environment was discussed with Staff 1 (ED), Staff 4 (Regional Director of Operations), and Staff 5 (Area Health & Wellness Director) on 08/29/23. Staff 4 provided the plan of correction.

Professional carpet cleaning service provided on 8/29/2023.  Apartment and public bathroom doors have been unlocked. Service plans have been updated to reflect those residents that are physically and cognitively able to use a key to lock and unlock their apartment doors. Training provided to associate concerning Resident right to room access on 8/29/2023. Survey team was provided with time cards as requested which showed that posted staffing pattern was followed and there was a minimum of 4 caregivers in the community during the day and evening shifts. 3. Professional carpet cleaners are scheduled monthly. On 8/22/2023 and 8/29/2023 staff received training on the use of the community carpet cleaner to assure that carpets are cleaned as quickly as possible. Associates were re-educated on resident room access policy on 8/30/2023.Associates were re-educated on resident rights on 8/30/23.   The Executive Director, Health & Wellness Director, Area Health & Wellness Director and Clare Bridge Program Coordinator were re-educated on resident rights by Divisional Dementia Care Manager on 8/30/2023.  This included behavior problem solving and brainstorming scenarios for two residents who frequently enter other resident apartments.  This team developed programming interventions. Assignment sheets which outlined scheduled showers were printed and all staff were trained on use of assignment sheets and how to document care refusals on 9/21/23. Executive Director and/or Health and Wellness Director will complete rounds 4 times daily a minimum of 4 days a week as part of standard operations. Executive Director, Maintenance Director, Health & Wellness Director or designee are responsible for this plan of correction.

3. During the survey on 01/22/24 through 01/24/24, the facility was found to have severe and pervasive urine odors. The odors were located in both neighborhoods in halls and common areas. The most significant areas were located in A hall, B hall, D hall and E hall. Dark brown and/or black stains were noted along doorways at the corner ends of the hallways and many stains were located in areas with strong odors. Red stains were additionally located along multiple hallways. Additionally, two smaller TV rooms areas had strong sour odors in addition to red, brown and/or black stains in the carpet. Several stains appeared to have possible solid spills within the stained area. The need to ensure residents were treated with dignity and respect, and had a safe, clean and home-like environment was discussed with Staff 1 (ED) and Staff 31 (Maintenance) on 01/23/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure 2 of 2 sampled residents (#s 13 and 17) and multiple non-sampled residents had a safe and homelike environment related to accessing their rooms and were treated with dignity and respect related to the condition of their environment. This is a repeat citation. Findings include, but are not limited to: 1. Resident 13 was admitted to the facility in 12/2023 with diagnoses including dementia and history of traumatic brain injury. Observation, interviews with staff and review of the resident's clinical record was completed, including most recent evaluation and service plan dated 12/20/23, temporary service plans (TSPs) and progress notes. The following was identified: On 01/22/24, the resident was observed going to his/her room with a staff member who unlocked the resident's room with a facility key. Resident 13 asked the staff member "What's so difficult about me getting a key for my door? I'd like to be able to lock my door and get in and out." The staff member stated "I'm not sure." During an interview with the resident on 01/22/24, s/he stated frustration with the fact that s/he did not have a key to get into his/her apartment. The resident stated that s/he propelled himself/herself via wheelchair independently throughout the facility, as well as toileting himself/herself independently, and did not like that s/he had to find a staff member in order to get into his/her apartment. The resident did not have a call pendant or other way to alert caregivers that s/he wanted to get into his/her room. Over a one-hour period on 01/22/24, the resident approached this surveyor three times to show that s/he had been locked out of his/her room, and could not easily find a staff member to unlock the door. It took the resident between 5 and 10 minutes to find a staff member to assist him/her. The resident continued to become increasingly agitated at being locked out of his/her room. During an interview with Staff 1 (ED) and Staff 34 (Health and Wellness Director/LPN), they stated the resident had not been given a key to the door because his/her previous roommate did not have the ability to use a key, so the door could not be locked at any time. They stated they did not know the resident's door was currently being locked, or how this was happening. There was no documented evidence the resident had been evaluated for the ability to have a key or the need to have his/her room locked or unlocked. The need to ensure a resident had a safe and homelike environment including access to his/her room was discussed with Staff 1, Staff 2 (Area Nurse Manager), Staff 34 and Staff 39 (Area Health and Wellness Director/RN) on 01/24/24. They acknowledged the findings. 2. Resident 17 was admitted to the facility in 11/2023 with diagnoses including dementia. Interviews with staff and review of the resident's clinical record was completed, including most recent service plan dated 12/07/23, temporary service plans (TSPs), and progress notes. The following was identified: On 01/23/24, Resident 17 was observed standing outside of his/her room, pushing on the door handle. Resident appeared to look around for a staff member, but no one was available. The resident stated "I need to get in to my room, but I'm locked out." The resident appeared to become frustrated and stated "How can I get into my room when I don't have a key." The resident paced up and down the hallway in front of his/her door for seven minutes before a caregiver entered the area and assisted in unlocking the door. On 01/24/24, Resident 17 was again observed standing in front of his/her room and stated "I'm locked out again." The resident did not have a way to call for assistance and no caregiver entered the area for over 10 minutes. The resident became increasingly agitated at being unable to enter his/her apartment. The need to ensure a resident had a safe and homelike environment including being able to access to his/her apartment was discussed with Staff 1 (ED), Staff 2 (Area Nurse Manager), Staff 34 (Health and Wellness Director/LPN) and Staff 39 (Area Health and Wellness Director/RN) on 01/24/24. They acknowledged the findings.

1. Residents 13 and 17 have received a key to their apartment. Carpet has been replaced in A and D hall.  Carpet stains and odors were addressed immediately during survey. Community carpet cleaning schedule has been implemented and professional monthly cleaning is scheduled. 2. Residents have been evaluated to establish their ability for appropriate use of an apartment key. Service plans have been updated to reflect ability.  Staff to receive education on the use of the carpet cleaning systems available to them and reporting maintenance concerns on or before 2/24/2024. Daily walk through of the community will be conducted to assure community cleanliness, sanitation, and odor control and maintenance concerns. Community carpet cleaning schedule has been implemented and professional monthly cleaning is scheduled. 3. Residents will be evaluated for ability to use a key to their apartment upon move in, quarterly and with change of condition. Executive Director or designee will complete community walk through to ensure that residents have access to their apartments a minimum of twice daily, 5 days per week. 4. Executive Director is responsible for this plan of correction

2. Resident 6 was admitted to the facility in December 2021 with diagnoses including dementia. Clinical Records revealed on 08/24/23 Resident 6 experienced an unwitnessed fall and sustained injuries to his/her face. The resident was sent to the local emergency room, and was diagnosed with a broken nose. The resident was placed on alert for the fall with injury upon return on 08/26/23. There was no documented evidence the facility had conducted a prompt investigation of the unwitnessed fall to rule out abuse and neglect, nor was there documented evidence the injury of unknown cause had been reported to the local SPD office. On 08/30/23, the need to ensure all investigations were conducted promptly after incidents, to rule out abuse and neglect was discussed with Staff 1 (Executive Director). She acknowledged the findings. Confirmation the incident had been reported was received on 08/31/23.

Based on interview and record review, it was determined the facility failed to ensure falls with injuries, injuries of unknown cause, and/or resident-to-resident altercations were investigated, investigated to reasonably rule out abuse and/or neglect, and/or were reported to the local Seniors and People with Disabilities (SPD) office for 2 of 10 sampled residents (#s 5 and 6). Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 12/2021 with diagnoses including Alzheimer's disease. The resident's current service plan, dated 08/17/23, progress notes dated 05/27/23 through 08/28/23, incident reports, and temporary service plans were reviewed, and staff were interviewed. The following was identified: a. The resident experienced 28 falls between 05/29/23 and 08/24/23. * On ten occasions the resident sustained injuries from falls. * The following unwitnessed falls were either not investigated in a timely manner to rule out abuse and/or neglect or the facility determined the resident's service plan was not being followed at the time of the incident: - 06/13/23, 6:20 pm - head laceration, received staples at the emergency room and interventions in place were not being used; - 06/15/23, 2:00 pm - no injury, interventions in place were not being used; - 06/23/23, 3:45 pm - no injury, no documented investigation; - 07/02/23, 8:00 pm - bump on the head, no documented investigation; - 07/05/23, 2:10 pm - no injury, no documented investigation; - 07/12/23, 9:00 am - skin tear on left knee, no documented investigation; - 07/17/23, 11:15 am - bump on back of head, no documented investigation; - 08/04/23, 4:45 pm - scrape/abrasion on "lower left side," no documented investigation; - 08/21/23, 7:00 am - previous stapled laceration bleeding, investigation not timely; - 08/21/23, 1:30 pm - no injury, investigation not timely; and - 08/23/23, 7:10 am - scrape/abrasion to left knee, "pool noodle" to be placed on the edge of the bed was on the other side of the room. b. On 08/17/23 at 7:00 am staff discovered Resident 5 in his/her bed with dried blood on the wall and the pillow, "a good amount of blood" on his/her back, and a puddle of blood in the bathroom. There was no documented investigation of the incident to rule out abuse and/or neglect, nor was it reported to the local SPD office. The need to investigate incidents in a timely manner to rule out abuse and/or neglect, and to report incidents to the local SPD office if abuse and/or neglect cannot be reasonably ruled out, was discussed with Staff 1 (ED) on 08/31/23 at 3:36 pm. She acknowledged the findings. The facility was asked to report the above incidents to the local SPD office during survey. Confirmations of the reports were received prior to exit.

Residents 5 and 6: Unreported events have been submitted as late reports to Adult Protective Services. Incidents from past 60 days will be reviewed to ensure proper investigation. Incidents will be reported to Adult Protective Services as required. Executive Director, Health & Wellness Director & Area Health & Wellness Director will receive re-education on incident investigation, including investigation of injuries of unknown cause and resident to resident altercations. The Community is partnering with a Nurse Consultant to provide incident investigation training for the Executive Director and community nurses. This re-education will include a review of sample of incidents to validate that appropriate investigations and interventions are present. Divisional Dementia Care Manager visited on 9/5-9/7/23 to complete staff re-education on resident engagement and behavior problem solving.  This re-education included working with associates to develop interventions for behaviors. Incidents will be reviewed during clinical meeting 4 days per week as part of standard operations. This review will include development of interventions, investigation, and reporting to Adult Protective Services as appropriate. The Executive Director and Health and Wellness Director is responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to investigate incidents or injuries of unknown cause to rule-out abuse, document all required areas of an investigation, and report to the local SPD office, if abuse could not reasonably be ruled out, for 2 of 5 sampled residents (#s 13 and 15) with incidents or injuries of unknown cause. This is a repeat citation. Findings include, but are not limited to: 1. Resident 15 was admitted to the facility in 11/2022 with diagnoses including Alzheimer's disease. Interviews with staff and review of the resident's clinical record was completed, including most recent service plan dated 12/11/23, temporary service plans (TSPs), incident reports, APS reports, outside provider communication and progress notes. The following was identified: * A progress note on 01/12/24 noted a resident to resident physical altercation, resulting in Resident 15 punching another resident in the stomach. During the same incident, Resident 15 attempted to hit a second resident and slapped a caregiver. There was no documented evidence the facility immediately reported the resident to resident altercation to the local SPD office. At the request of the survey team, the facility reported the incident to the local SPD and a confirmation was provided to the survey team prior to exit. There was no documented evidence the incident was promptly investigated and the facility took measures to prevent reoccurrence. The need to ensure all incidents were reported to the local SPD office and promptly investigated was discussed with Staff 1 (ED), Staff 2 (Area Nurse Manager), Staff 34 (Health and Wellness Director/LPN) and Staff 39 (Area Health and Wellness Director/RN) on 01/24/24. They acknowledged the findings. 2. Resident 13 was admitted to the facility in 12/2023 with diagnoses include dementia and history of traumatic brain injury. Interviews with staff and review of the resident's clinical record was completed, including most recent service plan dated 12/11/23, temporary service plans (TSPs), incident reports, APS reports, outside provider communication and progress notes. The following was identified: * A progress note dated 12/22/23 noted a resident to resident verbal altercation and attempted physical altercation with the resident's roommate, after which his/her roommate stated s/he did not want to share a room with him/her. * A progress note dated 12/23/23 noted a resident to resident verbal altercation with his/her roommate where Resident 13 stated "someone needs to kill [him/her]." * A progress note dated 01/12/24 noted a resident to resident physical altercation where Resident 13 was punched in the stomach by another resident. The survey team requested the facility report to the SPD office, and the facility provided verification that the report was submitted on 01/22/24. There was no documented evidence the incidents had been promptly investigated at the time of occurrence and were reported to the local SPD office if abuse could not be reasonably ruled out. The need to ensure all incidents were promptly investigated and were reported to the local SPD office if abuse could not be ruled out was discussed with Staff 1 (ED), Staff 2 (Area Nurse Manager), Staff 34 (Health and Wellness Director/LPN) and Staff 39 (Area Health and Wellness Director/RN) on 01/24/24. They acknowledged the findings.

1. Incidents for resident 13 and 15 were reported to Adult Protective Services during survey. 2. Events from the last 30 days have been reviewed to assure incidents were reported as Required to Adult Protective Services.  Community associates will receive training on "Elder Abuse Prevention, Investigation and reporting" provided by Oregon Care Partners online education series on or before March 9, 2024. Incidents will be reviewed 4-5 days a week during regular scheduled clinical meeting. This review will include ensuring that all incidents have proper investigation and that they are reported to APS as appropriate. 3. Clinical meeting will continue a minimum of 4-5 times each week as part of standard facility operations. 4. Executive Director and Health and Wellness Director are responsible for this plan of correction.

Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was kept clean and in good repair and food was palatable, in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to: 1. Observation of the kitchen on 08/28/23 at 9:08 am revealed the following areas needed cleaning and/or repair. Kitchen Area: * A two-compartment sink faucet handle was broken; * The entrance door jamb to the dish machine area had gouges and peeling paint; * The door by the walk-in refrigerator had gouges and was missing paint; * The front and sides of the toaster had dried food matter; * Two fans had dirt and debris on the blades blowing into the kitchen area where food was being prepared; * The wall behind the kitchen door had food spills and debris; * The soap dispenser near the hand washing sink had brown matter and food debris; * The wall above the three-compartment sink had food debris and brown matter; * Walls throughout the kitchen had dried-on food spills, smears, and splatters; * Stove front, side, inside, and knobs had dried food, dust, and debris; and * Oven pipes had an approximate one-inch layer of dust and debris. Dish washing area: * The wall throughout the area had brown matter, food spills, and debris; * The stainless steel counter had dried-on food matter on top and underneath; and * The floor had an accumulation of dirt, debris, and food matter. Floor: * The floor and baseboards had black matter build-up and food debris in the corners. In an interview with Staff 10 (Dietary Manager), the cleaning schedule was reviewed and had some documentation as items completed, however several areas were blank. Staff 10 stated the kitchen was short-staffed and cleaning was not completed as required. On 08/28/23 at approximately 10:30 am, the kitchen was toured with Staff 1 (ED) and the above areas were reviewed.  Staff 1 acknowledged the above areas needed cleaning and repair. 2. In an interview with Staff 9 (Cook), she mentioned that food often got cold quickly related to the facility not having plate warmers, hot carts were not used to transport food to individual units, and staff took a long time to collect the carts and distribute the food. A test tray was requested on 08/28/23 at 12:40 pm. The meal consisted of turkey with gravy, mixed vegetables, and stuffing. The food was lukewarm. The turkey, stuffing, and vegetables lacked flavor, had a mushy texture, and had a sodium taste. The gravy tasted of sodium and lacked flavor. The vegetables had a waxy after-taste. At 1:50 pm, the surveyor had a discussion with Staff 1 regarding test tray findings . Staff 1 verified she was unaware that the food palatability was poor. No further information was provided.

A deep clean of the kitchen was completed on 9/20/23 to address areas cited during survey. Kitchen repairs identified during survey have been evaluated by maintenance and will be completed by 10/29/2023. Dining Coordinator from sister community and Dining Protem visited community to ensure menus were created with fresh items and low sodium expectations. A kitchen cleaning schedule is in place to assure that cleaning tasks are being completed. New Dining Service Coordinator will be educated on or before 9/29/23 on menu expectations and pre-tasting of menu items prior to meal being served. Executive Director or designee will review cleaning checklist for completion a minimum of 4 days weekly. Executive Director or designee will review tasting log a minimum of 3 times weekly to confirm proper temperatures and flavor are present. Executive Director, Dining services Director or designee is responsible for this plan of correction.

Based on observation, interview, and record review, it was determined the facility failed to ensure a daily program of social and recreational activities based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to: During the survey, 08/28/23 through 08/31/23, observations of both neighborhoods and town square showed no group activities in the individual neighborhoods. There were one to three group activities conducted in the town square area located in the center of the two neighborhoods. The television was on throughout the day in both common areas of the neighborhoods. Residents from each neighborhood could attend activities in the town square. Several residents from each neighborhood remained in their individual neighborhoods and a few wandered between the two neighborhoods without attending any activity. In an interview on 08/29/23, Staff 8 (Program Director) indicated he worked Sunday to Thursday and his activity assistant worked Tuesday to Saturday. The activity assistant was currently out of the facility. Activities in the town square were scheduled several times a day and residents could come and go. Staff 8 did not have any specific activities he had on the schedule for individual neighborhoods. The need to ensure a daily activity program was provided for residents to address their mental, physical and psychosocial needs was reviewed with Staff 1 (ED) on 08/29/23 and 08/30/23. She acknowledged the findings.

On 8/30/2023 staff received re-education from the Divisional Dementia Care Manager on small group and individual resident engagement. Items to engage residents were purchased and have been placed in common areas of the community to support the residents in their individual interests. Associates were educated on engagement boxes on 9/7/23 by Divisional Dementia Care Manager. Executive Director and Health and Wellness Director will ensure residents are engaged during community rounds. Clare Bridge Program Coordinator will audit supplies weekly to ensure residents have access to engagement items. Executive Director, Programs Coordinator or designee is responsible for this plan of correction.

Based on observation, interview, and record review, it was determined the facility failed to ensure a daily program of social and recreational activities based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. This is a repeat citation. Findings include, but are not limited to: In an interview on 01/23/24, Staff 8 (Program Director) indicated he worked Sunday to Thursday and his activity assistant worked Tuesday to Saturday.  Activities in the town square were scheduled several times a day and residents could come and go. Staff 8 indicated he created activity boxes for each neighborhood and staff were educated on their use. The staff should be providing activities to the residents who did not attend activities in the town square. Staff 8 did not have any specific activities scheduled for the individual neighborhoods. Multiple care staff were interviewed between 01/23/24 and 01/24/24, from both neighborhoods, regarding activities in the neighborhoods and the activity boxes. One staff indicated there was not time to provide activities but she was aware of the boxes. Three staff indicated they were familiar with the activity boxes and felt they had plenty of time to get an activity box or complete an activity with residents if they chose to. One staff was not familiar with the activity boxes and had not utilized them with any residents. During the survey, 01/22/24 through 01/24/23, observations of both neighborhoods and town square showed no group activities in the individual neighborhoods. There were one to three group activities conducted in the town square area located in the center of the two neighborhoods. The television was on throughout the day in both common areas of the neighborhoods. Residents from each neighborhood could attend activities in the town square. Several residents from each neighborhood remained in their individual neighborhoods and a few wandered between the two neighborhoods without attending any activity. No activity boxes were observed in use. They were located on a cart, in an alcove of a small TV room in both neighborhoods. Staff were not observed to be doing activities with residents who did not leave their neighborhood. The need to ensure a daily activity program was provided for residents to address their mental, physical and psychosocial needs was reviewed with Staff 1 (ED) on 01/24/24. She acknowledged the findings.

1. On 1/31/24 staff received training in the use of supplies available and how to conduct small group and/or individual activities. This included staff reviewing items in program boxes and creating their own ideas on how to engage individual residents.  Executive Director, Resident Programs Coordinator and Health and Wellness Director received additional training on January 31, 2024 on completing regular organization in-services to provide staff with ongoing training on resident engagement. Binders were created on January 31, 2024 for each area with activities for staff use such as trivia, exercise, or discussion groups. 2. Community walk-throughs will be conducted a minimum of twice daily, 5 days per week by Executive Director or designee to ensure staff are aware of available supplies and are using them to engage residents that are not interested in large group program offerings. A schedule of recommended programs for each side has been created to provide guidance to associates with programs following the daily path and large group program schedule. Discussion on program calendar will occur with staff during regularly scheduled stand up meeting 3-4 times per week. 3. Community walk-throughs and regular stand up meetings will continue as part of standard facility operations. 4. Executive Director, Resident Programs Coordinator or designee is responsible for this plan of correction.

Based on observation, interview, and record review, it was determined the facility failed to ensure adequate assistance was provided with ADL care for sampled and non-sampled residents including bathing, toileting, and dressing. Findings include, but are not limited to: Observations of the facility from 08/28/23 to 08/30/23 showed multiple sampled and non-sampled residents who appeared disheveled and had not been showered for an extended period. Residents' hair was uncombed, greasy, and/or unclean. Residents observed had body odor and/or urine odor, as well as soiled or stained clothing. Several residents' clothing had dried food debris on pants and/or shirts. Resident fingernails were unkempt, with dried brown/black substances underneath the end of their nails. The need to ensure all residents received adequate ADL care to ensure they were kept clean and well-groomed was discussed with Staff 1 (ED), Staff 3 (Area Health & Wellness Director), and Staff 4 (Regional Director of Operations) on 08/29/23 and 08/30/23. The staff acknowledged the findings.

Immediate review of resident's acuity in the areas of dressing, grooming, showering assistance and toileting has been completed to assure accuracy of service plans to assure resident needs have been captured. Training was provided to staff concerning use of daily assignment sheets on 9/21/23.  Staff has received training regarding documentation of refusal of care on 9/21/2023. Review of documented refusals and completion of care will reviewed during clinical meetings a minimum of 4 days weekly. Executive Director, Health & Wellness Director, Area Health and Wellness Director or designee are responsible for this plan of correction.

2. Resident 5 was admitted to the facility in 12/2021 with diagnoses including Alzheimer's disease. A review of the resident's clinical record revealed his/her last quarterly evaluation was dated 05/17/23. There was no documented evidence the evaluation was updated in 08/2023 when his/her service plan was updated. The need to ensure evaluations were updated quarterly was discussed with Staff 1 (ED) on 08/31/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were being completed for 2 of 12 sampled residents (#s 4 and 5) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 07/2021 with diagnoses including dementia. a. The resident's quarterly evaluation was completed on 04/21/23. The next quarterly evaluation was due on 07/21/23 and was not completed.   b. Resident 4's 04/21/23 quarterly evaluation identified s/he was a smoker. There was no documented evidence of an updated smoking evaluation for Resident 3's ability to smoke safely. On 08/30/23, the need to ensure resident evaluations were completed at least quarterly was discussed with Staff 1 (ED). She acknowledged the findings.

Resident 4 and 5s smoking evaluations have been completed and available to staff. An audit was completed by 9/21/23 to assure each resident has a current evaluation completed. An audit will be completed to assure that quarterly evaluations have been completed and available to staff. Executive Director, Health & Wellness Director and Area Health & Wellness Director will be re-educated on community policy and state regulation regarding the resident evaluation by 9/29/2023 through Leading Age Administrator training and Role of the Nurse training. An Audit will be conducted of 5 residents per week for the next 60 days to ensure that all evaluations are present with service plan updates. Evaluations will be reviewed for completion during quarterly service planning process. Executive Director, Health & Wellness Director, Area Health and Wellness Director or designee are responsible for this plan of correction.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services, and were implemented by staff for 9 of 12 sampled residents (#s 1, 2, 3, 5, 7, 8, 9, 11, and 12) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in 06/2014 with diagnoses including dysphagia (swallowing difficulties), dementia, and pneumonia. Observations of the resident, interviews with staff, and review of the service plan, dated 08/17/23, revealed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not followed by staff in the following areas: * Bathing; * Two person transfers; * Meal assistance; * Compression stockings; and * Washing hands at meal times.   The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (ED) on 08/30/23. She acknowledged the findings. 2. Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 08/26/23, and progress notes, dated 06/03/23 to 08/29/23, were completed. Staff indicated the resident had poor safety awareness, but was able to get up on his/her own and move around the facility. The staff further indicated they provided full assistance with ADLs and encouraged the resident to help with the tasks that s/he could complete. The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not consistently implemented by staff in the following areas: * Safety interventions; * ADL assistance and ability to direct care; * Wrist brace placement; * Providing two showers a week; * Toileting schedule; and * Resident-to-resident altercations, behaviors, and interventions/activities to use. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently followed was discussed with Staff 1 (ED) on 08/30/23. She acknowledged the findings. 3. Resident 7 was admitted to the facility in 04/2022 with diagnoses including dementia and anxiety. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 06/04/23, and progress notes, dated 05/27/23 to 08/28/23, were completed. Staff indicated the resident required full assistance with all care. The resident was able to transfer and ambulate on his/her own, but was very confused and extremely anxious. The resident's service plan was not reflective, lacked direction for staff, and/or was not consistently implemented by staff in the following areas: * ADL assistance and directing his/her own care; * Ankle swelling and interventions; * Inability to make decisions on own; * Fall interventions including fall mat and pool noodle; * Providing two showers a week; * Anxiety, distressed statements and interventions to comfort the resident; * Meal assistance; and * Activities to engage the resident and re-direct from distressed behaviors. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently followed was discussed with Staff 1 (ED) on 08/30/23. She acknowledged the findings. 4. Resident 11 was admitted to the facility in 02/2023 with diagnoses including dementia and anxiety. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 06/28/23, and progress notes, dated 05/28/23 to 08/11/23, were completed. Staff indicated the resident required full assistance with all care. The resident was able to transfer and ambulate on his/her own, but was very confused and difficult to re-direct. The resident had minimal verbal communication and frequently grabbed food and fluid items from wherever they were sitting. The resident's service plan was not reflective, lacked direction for staff, and/or was not consistently implemented by staff in the following areas: * ADL assistance and directing his/her own care; * Inability to make decisions on own; *Toileting schedule and history of putting his/her hands in soiled briefs; * Providing two showers a week; * Meal assistance and redirection; and * Activities to engage the resident and re-direct behaviors. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently followed was discussed with Staff 1 (ED) on 08/29/23. She acknowledged the findings. 5. Resident 3 was admitted to the facility in 02/2018 with diagnoses including dementia and hypertension. The current service plan, dated 06/18/23, was reviewed. The service plan was not reflective of the resident's current status and care needs and did not provide clear direction to staff in the following areas: * Two-person assistance with incontinence care provided in bed; * Use of a tilt-in-space wheelchair; * Skin condition and treatment to right big toe; and * How often to provide "purposeful safety checks." Observations on 08/28/23 through 08/30/23 revealed the service plan was not followed in the following areas: * Repositioning while the resident was in his/her wheelchair; and * Providing snacks and hydration between meals. The need to ensure service plans were reflective of the resident's current care needs, provided clear directions to staff, and were followed was discussed with Staff 1 (ED) on 08/31/23. She acknowledged the findings. 6. Resident 8 was admitted to the facility in 04/2022 with diagnoses including osteoarthritis, spinal stenosis, Crohn's disease, and chronic pain syndrome. Review of Resident 8's 07/14/23 service plan, interviews with staff, and observations of the resident revealed the service plan was not reflective of his/her current status and care needs and did not provide clear direction to staff in the following areas: * How often to provide "purposeful safety checks;" * How often to provide toileting assistance; and * How often to check and empty ostomy bag. Observations on 08/28/23 through 08/30/23 revealed the service plan was not followed in the following areas: * Two-person assistance with transfers and toileting. The need to ensure service plans were reflective of the resident's current care needs, provided clear directions to staff, and were followed was discussed with Staff 1 (ED) on 08/31/23. She acknowledged the findings. 7. Resident 12 was admitted to the facility in 10/2022 with diagnoses including dementia and congestive heart failure. Review of Resident 12's 06/04/23 service plan, interviews with staff, and observations of the resident revealed the service plan was not reflective of his/her current status and care needs and did not provide clear direction to staff in the following areas: * Staff assistance with transfers and toileting; * Use of wheelchair for mobility; * Staff assistance with meals; * Recent falls, injuries, and interventions to minimize falls; and * How often to provide "purposeful safety checks." The need to ensure service plans were reflective of the resident's current status and care needs and provided clear direction to staff was discussed with Staff 1 (ED) on 08/31/23. She acknowledged the findings. 8. Resident 2 was admitted to the facility in 07/2023 with diagnoses including macular degeneration, chronic kidney disease, and retention of urine. Review of the resident's current service plan, dated 07/29/23, observations of the resident, and staff interviews revealed it was not reflective of his/her current status and care needs in the following areas: * Use of assistive devices for ambulation; and * Where the resident slept. The need to ensure service plans accurately reflected residents' current status and care needs was discussed with Staff 1 (ED) on 08/31/23. She acknowledged the findings. 9. Resident 5 was admitted to the facility in 12/2021 with diagnoses including Alzheimer's disease. Review of the resident's current service plan, dated 08/17/23, observations of the resident, and staff interviews revealed it was not reflective of his/her current status and care needs in the following areas: * Level and frequency of assistance needed with meals; * Ability to complete ADLs independently; * Transfer assistance needed; and * Assistance needed with toileting. The need to ensure service plans accurately reflected residents' current status and care needs was discussed with Staff 1 (ED) on 08/31/23. She acknowledged the findings.

The service plans of Residents 1, 2, 3, 5, 7, 8, 9, 11 and 12 have been reviewed by the interdisciplinary team at the community and updated to reflect current needs. Service plans will be reviewed by members from each discipline of the community to verify that care needs are captured and current at quarterly review. This will include eliciting feedback from direct care staff. Service plans will be reviewed on move in, quarterly and upon change of condition as part of standard operations Executive Director, Health & Wellness Director, Area Health and Wellness Director or designee are responsible for this plan of correction.

2. Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 08/26/23, and progress notes, dated 06/03/23 to 08/29/23, were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Skin tear to the forearm and the elbow; * Elopement; and * Verbal threats towards another resident. The need to ensure there was documentation to reflect monitoring of short-term changes of condition at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) on 08/29/23. She acknowledged the findings. 3. Resident 7 was admitted to the facility in 04/2022 with diagnoses including dementia and anxiety. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 06/04/23, and progress notes, dated 05/27/23 to 08/28/23, were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Multiple medication changes; * COVID booster; * Increased anxiety, fear, and behaviors; * Picking at skin and increased crying; * Yellowing of skin and emergency room visit. The need to ensure there was documentation to reflect monitoring of short-term changes of condition at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) on 08/30/23. She acknowledged the findings. 4. Resident 10 was admitted to the facility in 02/2023 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 06/28/23, and progress notes, dated 05/30/23 to 08/28/23, were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Medication error; * Nose bleed; and * Resident-to-resident altercation. The need to ensure there was documentation to reflect monitoring of short-term changes of condition at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) on 08/29/23. She acknowledged the findings. 5. Resident 11 was admitted to the facility in 02/2023 with diagnoses including dementia and anxiety. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 06/28/23, and progress notes, dated 05/28/23 to 08/11/23, were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Sunburn; * Sore with scabbed area to right wrist; * Choking incident. The need to ensure there was documentation to reflect monitoring of short-term changes of condition at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) on 08/29/23. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine and document what action or intervention was needed for a resident, communicate the interventions to staff on each shift, ensure interventions were resident-specific, and monitor the resident consistent with his/her evaluated needs and service plan with weekly progress noted until the condition resolves for 7 of 11 sampled residents ( #s 1, 2, 6, 7, 8, 10, and 11) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 04/2022 with diagnoses including osteoarthritis, spinal stenosis, Crohn's disease, and chronic pain syndrome. Observations of the resident, interviews with staff, and review of the resident's 07/14/23 service plan and progress notes from 05/27/23 through 08/28/23 identified the resident experienced multiple short-term changes of condition in the following areas: * 06/23/23 - Increased lower back pain; * 07/05/23 - "Resident had small amount of yellowish green [genital] discharge in brief"; * 07/09/23 - Blood in ileostomy bag, ER visit, diagnosed with a parastomal hernia; * 07/10/23 - Noted decline in appetite; * 08/11/23 - Non-injury fall; 08/15/23 - Home health PT progress note documented the resident complained of "burning with urination, dizziness in sitting, and hypotension at rest"; and * 08/17/23 - New antibiotic medication. There was no documented evidence the facility consistently evaluated changes of condition the resident experienced, determined actions or interventions specific to each change of condition, updated the service plan as needed, or monitored and documented the progress of the condition at least weekly until resolved. On 08/31/23, the need to ensure the facility evaluated, determined and documented what actions or interventions were needed for changes of condition, and monitored until resolution was reviewed with Staff 1 (ED). She acknowledged the findings. 6. Resident 6 was admitted to the facility in 12/2021 with diagnoses including dementia. Interviews with staff and review of Resident 6's clinical records, including incident reports, progress notes dated 06/02/23 through 08/28/23, and service plan revealed the following: * Progress notes dated 08/24/23 indicated Resident 6 experienced an unwitnessed fall with injury. The fall resulted in Resident 6 sustaining abrasions to the face and a broken nose. There was no documented evidence the facility evaluated the resident to determine what actions or interventions were needed to minimize the further occurrence of falls. On 08/30/23, the need to ensure residents who experienced changes of condition had resident-specific interventions determined, documented, and communicated to staff was discussed with Staff 1 (ED). She acknowledged the findings. 7. Resident 2 was admitted to the facility in 07/2023 with diagnoses including macular degeneration, chronic kidney disease, and retention of urine. The resident's clinical record was reviewed, including progress notes dated 07/29/23 through 08/28/23, temporary service plans, and weight records. The following was identified: * Between 07/08/23 and 08/02/23, the resident gained 11.8 pounds, or 8.6% of his/her total body weight. * There was no documented evidence the facility RN was notified of the resident's severe weight gain or the change of condition was monitored through resolution. The need for changes of condition to be evaluated and referred to the RN when needed, as well as to be monitored through resolution with at least weekly documentation, was discussed with Staff 1 (ED) on 08/31/23. She acknowledged the findings.

The records for Residents 1, 2, 6, 7, 8, 10 and 11 have been reviewed and updated where necessary in relation to the short term changes referenced in the deficiency report.  An audit of the other residents will be completed by 10/29/2023. The Medication Technicians will be re-educated on change of condition documentation to reflect weekly charting until resolved on 9/28/2023.  Health & Wellness Director and Area Health & Wellness Director/RN have attended the Role of the Nurse course through Leading Age September 12-14, 2023.   Resident changes in condition will be discussed during routine staff stand up meeting, audited and reviewed by the clinical team during clinical meeting 4 days per week as part of standard operations. Executive Director, Health & Wellness Director, Area Health and Wellness Director or designee are responsible for this plan of correction.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short-term or significant changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, and progress was documented weekly until resolution for 3 of 7 sampled residents (#s 13, 15 and 17). Resident 15 experienced significant unaddressed agitation, aggression, and repeated resident to resident altercations. This is a repeat citation. Findings include, but are not limited to: 1. Resident 15 was admitted to the facility 11/2022 with diagnoses including Alzheimer's disease. Observations of the resident, interviews with staff, and review of the resident's clinical record was completed, including most recent service plan dated 12/11/23, temporary service plans (TSPs), incident reports, APS reports, outside provider communication and progress notes. The following changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly through resolution and/or referral to the nurse for evaluation: * 12/15/23: Resident to resident verbal altercation; * 12/15/23: Unwitnessed fall with report of resident hitting his/her head; * 12/18/23: New symptom presentation including being unstable on his/her feet and high blood pressure. * 01/09/24: Resident to resident physical altercations resulting in Resident 15 punching a resident and hitting a resident, a resident's family member, and multiple care staff. The resident was sent to the emergency room (ER) and returned a few hours later. Instructions to staff stated to "redirect resident," remove others, and call 911; all other instructions were not specific to the resident; * 01/11/24: Verbal aggression to staff, opening windows and attempting to elope. Instructions to staff include highlighted form stating "Offer 1:1, offer reassurance, listen and use validation." * 01/12/24: Resident to resident altercations beginning with verbal altercation and progressing to Resident 15 punching another resident, attempting to hit a third resident, and slapping a caregiver. The resident was sent to the ER and returned a few hours later. There was no change in the instructions provided to caregivers on all shifts; * 01/15/24: Resident verbally abusive to staff while walking halls for "about an hour, resident was "frantic;" * 01/16/24: Resident attempted to hit two other residents, staff intervened before contact was made. No new interventions or instructions to staff were implemented; * 01/20/24: Resident to resident physical altercation resulting in Resident 15 hitting another resident; resident was noted to have unsteady gait and slurred speech. Resident was sent to the ER and returned a few hours later. Instructions to staff stated "redirect to a quiet place." Between the dates of 01/09/24 and 01/20/24, the resident experienced multiple short term changes of condition which did not have determined and documented actions and interventions which were specific to the resident, and were not referred to the facility nurse for evaluation. This resulted in repeated physical altercations with other residents in the facility, which constitutes harm. The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (ED), Staff 2 (Area Nurse Manager), Staff 34 (Health and Wellness Director/LPN) and Staff 39 (Area Health and Wellness Director/RN) on 01/24/24. They acknowledged the findings. 2. Resident 13 was admitted to the facility in 12/2023 with diagnoses including dementia and history of traumatic brain injury. Observations of the resident, interviews with staff, and review of the resident's clinical record was completed, including most recent service plan dated 12/20/23, temporary service plans (TSPs), incident reports, APS reports, outside provider communication and progress notes. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, had progress noted at least weekly through resolution and/or referral to the nurse for evaluation: *12/22/23: Resident to resident altercation when Resident 13 smacked a muffin out of his/her roommate's hand and then attempted to grab his/her roommate. The roommate was visibly upset and stated that s/he did not want to share a room with Resident 13. *12/23/23: Resident to resident verbal altercation with roommate, when Resident 13 stated "someone needs to kill [him/her]." *12/29/23: New onset of back pain requiring PRN medication multiple days in a row. *1/12/24: Resident to resident physical altercation when Resident 13 was punched in the stomach by another resident. The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (ED), Staff 2 (Area Nurse Manager), Staff 34 (Health and Wellness Director/LPN) and Staff 39 (Area Health and Wellness Director/RN) on 01/24/24. They acknowledged the findings. 3. Resident 17 was admitted to the facility in 11/2023 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's clinical record was completed, including most recent service plan dated 12/07/23, temporary service plans (TSPs), incident reports, APS reports, outside provider communication and progress notes. The following changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly through resolution and/or were not referred to the facility nurse for evaluation: *12/13/23: Bruising to both legs and right hip; *12/26/23: Right foot swelling; *12/27/23: Bilateral foot swelling; *12/28/23: New medication, sertraline (for dementia); and *01/10/24: Change in weight. The need to ensure actions or interventions for changes of condition were documented, communicated to staff on each shift, the changes of condition were monitored through resolution and staff referred changes of condition to the facility nurse for evaluation was discussed with Staff 1 (ED), Staff 2 (Area Nurse Manager), Staff 34 (Health and Wellness Director/LPN) and Staff 39 (Area Health and Wellness Director/RN) on 01/24/24. They acknowledged the findings.

1. Change of condition for residents 13, 15 and 17 were completed on or before 1/31/24. Education with community clinical team on Brookdale policies and procedures on significant and short term change of condition and effective monitoring and assessment was provided by District Director of Clinical Operations Specialist on January 26, 2024. Med techs received education on recognizing and reporting residents experiencing a change of condition on January 31, 2024. 2. Incident reports from past 60 days were reviewed by community team and District Director of Clinical Operations by January 30,2024. This review included identifying any residents who may have experienced a change of condition. 3. Progress notes and incident reports will be reviewed during regularly scheduled clinical meeting 4-5 days per week. This will continue as part of community standard practice. 4. Executive Director, Health and Wellness Director are responsible for this plan of correction

3. Resident 2 was admitted to the facility in 07/2023 with diagnoses including macular degeneration, chronic kidney disease, and retention of urine. A review of Resident 2's clinical record, including the current service plan, dated 07/29/23, progress notes dated 07/29/23 through 08/28/23, and weight records was completed, and staff were interviewed. The following was identified: * 07/08/23 - 136.6 pounds; and * 08/02/23 - 148.4 pounds. The resident gained 11.8 pounds, or 8.6% of his/her total body weight, in 30 days, which constituted a severe weight gain and a significant change of condition. There was no documented evidence a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN. Staff 2 (Area Health & Wellness Director) provided an RN assessment for the resident's weight gain on 08/31/23. The need for an RN to assess all significant changes of condition in a timely manner was discussed with Staff 1 (ED) on 08/31/23. She acknowledged the findings. 2. Resident 8 was admitted to the facility in 04/2022 with diagnoses including osteoarthritis, spinal stenosis, Crohn's disease, and chronic pain syndrome. Resident 8's weight records were reviewed and revealed the following: * 07/02/23 - 129.2 pounds; and * 08/02/23 - 121.8 pounds. From 07/02/23 to 08/02/23, Resident 8 had a weight loss of 7.4 pounds, or 5.72% of his/her total body weight, in one month. The weight loss indicated a significant change of condition and required an RN assessment. There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition. On 08/31/23 at 10:15 am, Staff 2 (Area Health & Wellness Director) confirmed there was no nursing assessment for the weight loss. Between 08/28/23 and  08/31/23, Resident 8 was observed during mealtimes. The resident ate approximately 30% to 40 % of breakfast and lunch meals. The resident was independent with eating, and due to vision loss staff were to position utensils and food items on the resident's left side. On 08/31/23 at 1:45 pm Staff 2 informed surveyor she had just completed an RN assessment for the significant weight loss, with interventions of health shakes three times a day and weekly weights. A copy of the RN assessment was provided. The need to ensure an RN assessment was completed for all residents who experienced a significant change of condition was discussed with Staff 1 (ED) on 08/31/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 9 sampled residents (#s 2, 6, and 8) who experienced significant changes of condition were assessed by the RN. Findings include but are not limited to: 1. Resident 6 was admitted to the facility in 12/2021 with diagnoses including dementia. A review of progress notes indicated the resident was sent to the emergency room on 08/24/23 after experiencing a fall. S/he returned with a diagnosis of a broken nose on 08/26/23. The new diagnosis of a broken nose represented a significant change of condition for the resident. There was no documented evidence an RN assessment was completed which documented findings, resident status, and interventions made because of the assessment. On 08/30/23 the need to conduct an RN assessment following a significant change in condition was discussed with Staff 1 (ED), She acknowledged the findings.

Resident 2, 6 and 8:  Significant change of condition assessments have been completed by the RN and documentation entered into the resident record. Resident records for those with a known fracture or pattern of weight loss or gain will be reviewed by the RN for proper evaluation and preventative measures as appropriate and documentation is reflected in the resident record. Area Health & Wellness Director (RN) has been educated on state regulation as it relates to significant changes of condition.  Associates will be educated on proper reporting of changes in condition and related documentation by 9/28/2023.  Resident changes in condition will be discussed during routine staff stand up meeting and reviewed by the clinical team during routine meeting. The clinical team will meet and review change of conditions during routine clinical meeting 4 days weekly as part of standard operations. Executive Director, Health and Wellness Director and Area Health & Wellness Director are responsible for this plan of correction.

Based on observation, interview, and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN and the service plan was updated by the RN for 1 of 5 sampled residents (#15) reviewed for significant changes of condition. This is a repeat citation. Findings include, but are not limited to: Resident 15 was admitted to the facility in 11/2022 with diagnoses including Alzheimer's disease. The resident's clinical record including the current evaluation and service plan, temporary service plans (TSPs), and progress notes dated 12/13/23 through 01/21/24 was reviewed, the resident was observed and staff were interviewed. The following was identified: During an 11 day period from 01/09/24 through 01/20/24, Resident 15 experienced significant agitation which resulted in three emergency room visits. While agitated, s/he physically assaulted four residents, attempted to assault or verbally assaulted at least four additional residents, and physically assaulted multiple caregivers and multiple resident's family members or visitors. Progress notes from staff on 01/09/24 stated "this behavior is unlike residents baseline behavior." During an interview on 01/23/24, Staff 1 (ED) agreed that this was not typical behavior for Resident 15. On 01/24/24, Staff 39 (Area Health and Wellness Director/RN) stated the events above did indicate a significant change in the resident's behavior and acknowledged that she did not complete an assessment or institute specific interventions for the resident. The need to ensure an RN assessed all significant changes of condition including findings, resident status, and interventions made as a result of the assessment within 48 hours was discussed with Staff 1, Staff 2 (Area Nurse Manager), Staff 34 (Health and Wellness Director/LPN) and Staff 39 on 01/24/24. They acknowledged the findings, and no additional documentation was provided.

1. The Area Health & Wellness Director assessed Resident 15 and updated the record to include resident specific interventions to address behavior. 2. Incident reports from past 60 days were reviewed by District Director of Clinical Operations to identify any residents who may be experiencing a change of condition. Any residents who were identified to have a change in behavior or status were referred to facility RN for assessment and follow up. RN completed a change of condition assessment and plan for any resident identified during this review. 3.Progress notes and incident reports will be reviewed during regularly scheduled clinical meeting 4-5 days per week. Any residents identified to be experiencing a change from baseline will be referred to facility RN for assessment and follow up. 4. Executive Director, Health and Wellness Director, and Area Health and Wellness Director are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 1 of 1 sampled resident (#8) who received outside services. Findings include, but are not limited to: Resident 8 was admitted to the facility in 04/2022 with diagnoses including osteoarthritis, spinal stenosis, Crohn's disease, and chronic pain syndrome. During the acuity interview on 08/28/23, the resident was identified to receive home health PT services. Resident 8's outside provider documentation from 07/28/23 through 08/25/23 was reviewed during the survey and revealed the following recommendations: * 07/28/23 - the home exercise program instructions were changed; * 08/03/23 - use a heating pad to low back following ambulation for 20 minutes on medium setting; * 08/08/23 - "Please consider offering to assist patient with placing towel roll at low back when in recliner as tolerated"; and * 08/23/23 - assist resident in placing lumbar towel roll at low back and heating pad at low setting after meals for 15-20 minutes. There was no documented evidence staff were informed of new interventions and the service plan adjusted to ensure continuity of care. An interview on 08/29/23, Witness 1 (Family Member) stated the facility was not assisting the resident with the above pain management techniques. The need to ensure the facility coordinated care with outside service providers and communicated recommendations for staff to follow was discussed with Staff 1 (ED) on 08/31/23. She acknowledged the findings.

Res 8: Service plan has been updated to reflect physical therapy recommendation. Outside provider notes will be reviewed and confirmed during the triple check process of  orders. Outside provider notes will be reviewed for proper processing and implementation during routine clinical meeting Executive Director, Health & Wellness Director, Area Health and Wellness Director or designee are responsible for this plan of correction.

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT and included documentation of less restrictive alternatives tried prior to use and instruction to staff on the correct use of and precautions for the device was included in the resident's evaluation and service plan for 1 of 1 sampled resident (#3) who had a tilt-in-space wheelchair. Findings include, but are not limited to: Resident 3 was admitted to the facility in 02/2018 with diagnoses including dementia. On 08/28/23 through 08/31/23 the resident was observed in a tilt-in-space wheelchair. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT, or OT, no documentation of less restrictive alternatives tried prior to use, and instruction to caregivers on the correct use of and precautions for a tilt-in-space wheelchair had not been included in the resident's evaluation and service plan. In an interview with Staff 2 (Area Health and Wellness Director) on 08/30/23, she confirmed the above information had not been completed or documented in the resident's record. The need to complete all required elements related to use of an assistive device with restraining qualities was discussed with Staff 1 (ED) on 08/31/23. She acknowledged the findings.

Resident 3's use of a special wheelchair has been assessed and documented to reflect in the record by the RN. An audit was conducted to identify any other residents using devices with restraining qualities. RN was provided re-education on community policy regarding devices with restraining qualities on 9/22/23. The use of a device with restraining qualities will be assessed prior to residents use as part of standard operations. This will be discussed during routine clinical meeting. Executive Director and Area Health & Wellness Director (RN) are responsible for this plan of correction

Based on observation, interview, and record review, it was determined the facility failed to have staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of non-sampled residents and sampled residents. Findings include, but are not limited to: During the survey, from 08/28/23 through 08/31/23, multiple staff reported there were frequently an insufficient number of staff in the building. Observations were made and staff and residents (sampled and non-sampled) were interviewed during the survey. The following was noted: * Multiple daily observations of both the Clare and Bridge neighborhoods, between 08/28/23 and 08/30/23, showed common areas were unsupervised by staff for periods of 10 to 20 minutes while numerous residents were present. The neighborhoods each had two television (TV) common areas. Residents were placed in the TV rooms before and after meals. The smaller TV room had two to four residents present during observations and the larger TV room had four to twelve residents present during observations throughout the survey. * On 08/28/23 at approximately 11:12 am, two residents were observed in the Clare neighborhood's large TV room seated next to each other. There were no staff present in the room. Resident 10 yelled at a non-sampled resident and then grabbed his/her arm and squeezed. Resident 10 shook the non-sampled resident's arm while squeezing their wrist. Resident 10 continued to yell at the non-sampled resident, grabbed the resident's clothing at the shoulder, and shook him/her while pulling the clothing down and towards him/her. During this altercation, no staff were visible nearby. The surveyor stepped between the residents and asked Resident 10 if s/he needed help and would s/he please let go of the other resident. Resident 10 released the non-sampled resident and yelled that the other resident had done the same thing to Resident 10. Resident 10 was very agitated. The surveyor checked the halls for staff and informed Staff 12 (MT) what had occurred. Staff 12 acknowledged the information and left the TV room. Staff 12 returned a few minutes later, checked the arms/shoulders of both residents, asked each of them if they were ok, and left the room. The residents were not separated or seated elsewhere in the TV room. The residents continued to be unsupervised for extended periods until lunch time when staff moved all residents to the dining room. The incident was reported to Staff 1 (ED) by the surveyor as well as Staff 12 (MT) on 08/28/23. * Resident 11 was observed on multiple days of the survey to wander the halls, in and out of the courtyard, TV rooms, apartments, offices, and the dining room. The resident frequently grabbed other residents' foods and drinks and required nearly continuous re-direction by staff, especially during meals. The resident grabbed items out of the pantry refrigerator and freezer, along with others' health shakes and drinks. Staff interviewed on 08/29/23 and 08/30/23 indicated the resident frequently required 1:1 staff attention, especially during meals, to keep him/her out of others' food and drink items. The resident was typically very active and on-the-move constantly. Staff stated the resident grabbing food items did not necessarily correlate to his/her own thirst and hunger. Staff further indicated there was no predictor of the behavior or way to get the resident to stop. The resident could sometimes be re-directed and at other times would become agitated when attempts were made to stop what s/he was doing. Staff stated the resident required a lot of staff time for his/her care and behavior monitoring, which was frequently difficult to provide, depending on staffing levels. * Observations on 08/28/23 and 08/29/23 revealed many residents were disheveled, hair was matted, fingernails had black matter underneath them, clothes had dried-on food matter, and there was dried-on food matter, dust, and debris on wheelchairs. * In an interview with Staff 23 (MT/CG) on 08/28/23, s/he stated the residents were not showered the week of 08/14/23 through 08/18/23 and "very few" residents got showered the week of 08/21/23 through 08/25/23, related to being "short-staffed." Staff 23 stated for one month s/he had 28 residents to attend to as a caregiver, with "no support from management." S/he reported his/her last day working at the facility was 08/28/23. Staff 23 further stated residents' wheelchairs had not been cleaned for a while because there was "no time" to clean them. * In an interview on 08/28/23, Staff 13 (MT/CG) reported most day shifts were not fully staffed, and the facility was not meeting it's posted staffing plan of 1 MT and 2 CGs each on the Clare and Bridge neighborhoods. * A caregiver interviewed on 08/31/23 reported s/he was "lucky" if s/he "got one shower done a shift." * Several residents required meal oversight and/or full meal assistance. * Four residents required two-person assistance with transfers. * Multiple times throughout the survey, common areas of both neighborhoods were left unsupervised with no staff present. * There was a lack of scheduled and unscheduled activities provided for residents living in the MCC, and several residents were seated in front of the TV for long periods of time with no activities or engagement with staff. * During interviews, several staff confirmed the facility was short-staffed on a regular basis. Staff stated showers and ADLs were often missed due to lack of staffing. Staff reported weekends were especially bad, with one CG and one MT each on the Clare and Bridge neighborhoods. A caregiver working at the facility for over three months stated s/he had just recently been told where the resident service plans were kept. * Surveyor requested staff assistance for resident care on multiple occasions. The lack of services related to bathing, grooming, dressing, and toileting, along with staff providing inappropriate meal assistance for some residents, the lack of resident supervision, and ongoing staff complaints was reviewed and discussed during the survey. The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents was discussed with Staff 1 (ED) on 08/31/23. No further information was provided.

During survey, staff were reminded to provide oversight and supervision in areas where multiple residents are present. Staff were provided with education on engaging residents on 9/7/23 as well as on the behavioral problem solving process. Community team will continue to evaluate resident needs and adjust staffing as required. Executive Director and Health and Wellness Director will ensure staff are present in areas where residents are present as part of their community rounds. The Executive Director and Health and Wellness Director are responsible for this plan of correction.

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: The facility's ABST was reviewed on 08/30/23. There was no documented evidence all 22 required ADLs were addressed separately on the acuity-based staffing tool the facility was using. The need to have all required ADLs listed separately on the ABST was discussed with Staff 1 (ED) on 08/31/23. No further information was provided.

Report showing acuity based staffing minutes were provided during survey

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. This is a repeat citation. Findings include, but are not limited to: The facility's ABST was reviewed on 01/23/24. There was no documented evidence all 22 required ADLs were addressed separately on the ABST staffing tool the facility was using. The need to have all required ADLs listed separately on the ABST was discussed with Staff 1 (ED) on 01/23/24. No further information was provided.

1.As we continue to partner with DHS on reviewing our ABST tool, we will continue to staff using the Brookdale acuity based staffing tool. 2. Brookdale continues to work with DHS regarding the ABST tool and the 22 elements that make up the ABST tool.  We will continue to staff at the levels currently identified in our tool. 3. The Health and Wellness Director/Resident Care Coordinator will review the acuity based staffing tool and current staff schedules to confirm that the staffing scheduled is consistent with the scheduled and unscheduled needs of the residents. 4. The Executive Director is responsible to verify that staffing levels are appropriate as defined by our staffing tool.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. This is a repeat citation. Findings include, but are not limited to: The facility's ABST was reviewed on 04/01/24. There was no documented evidence all 22 required activities of daily living were addressed separately on the ABST staffing tool the facility was using. The need to use an ABST which addressed all of the 22 activities of daily living for each resident and the amount of staff time needed to provide care was discussed with Staff 4 (District Director of Operations) on 04/05/24. She acknowledged the findings.

1. As we continue to partner with DHS on reviewing our ABST tool, we will continue to staff According to our Brookdale acuity based staffing tool. 2. Our home office team will continue to establish proper communication with DHS regarding The ABST tool and the 22 elements that make up the ABST tool, we will continue to staff at or Above staffing levels currently identified in our tool. 3.  This will be evaluated by the Health and Wellness Director/Resident Care Coordinator to ensure that proper staffing levels are scheduled according to the 22 elements to ensure the scheduled and unscheduled needs of the residents are being met. 4. The Executive Director is responsible to ensure that our staffing levels are appropriate as defined by our staffing tool

Based on observation and interview, it was determined the facility failed to ensure the facility was clean, in good repair, and free of unpleasant odors. Findings include, but are not limited to: Observations of the Bridge and Clare memory care units from 08/28/23 through 08/30/23 revealed the following: * Multiple areas of carpet in hallways and corridors were observed with dark stains throughout the facility; * Multiple walls, baseboards, doors, and door frames throughout the facility were dinged, chipped, gouged, scraped, and/or had black streaks; * Multiple handrails were worn to bare wood and chipped; * A wall in unit E 6 was missing drywall and bare metal was exposed; * Window blinds in units A 7 and E 5 were broken and in need of repair; * There was fecal matter on the floor in "A hall"; and * There was a strong, pervasive urine odor detected throughout both communities, which failed to dissipate over the course of the survey. On 08/29/23, the areas in need of cleaning and repair, as well as the areas with unpleasant odors, were discussed with and shown to Staff 1 (ED). She acknowledged the findings.

Professional carpet cleaners provided carpet cleaning services on 8/29/2023. Disrepairs identified will be addressed and repaired by 10/29/2023 Staff has received training on the use of the building management program (TELS). Staff willbe re-educated on the reporting of identified community maintenance concerns. Maintenance concerns will be discussed at daily stand up TELS (building management program) will be reviewed daily. Executive Director and Maintenance Director are responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure the facility was clean, in good repair, and free of unpleasant odors. This is a repeat citation. Findings include, but are not limited to: Observations of both neighborhoods of the memory care units from 01/22/24 through 01/24/24 revealed the following: * Multiple areas of carpet in hallways and corridors were observed with dark red, black and/or brown stains throughout the facility; * A window sill in the large TV room and a striped chair had large amounts of dried nasal mucous on the surfaces; * There was significant, pungent and pervasive urine odors in A hall, B hall, D hall and E hall that did not dissipate during survey. Additionally, a mix of strong urine odors and sour odors were noted in the unused dining rooms and small TV rooms in both neighborhoods; and * Numerous pieces of furniture in the large and small TV rooms had stains, spills and debris to the arms, sides and seats. One arm chair additionally had a torn seat. On 01/23/24, the areas in need of cleaning and repair, as well as the areas with unpleasant odors, were discussed with and shown to Staff 1 (ED). She acknowledged the findings.

1. Carpets, window sills, furniture and odors were addressed during survey and were either cleaned, repaired, and/or removed. 2. Executive Director and Maintenance Supervisor completed community walk-through on January 25, 2024 to identify and complete work orders for any additional areas in need of cleaning or repair.  Carpet in A and D hall have been replaced. 3. Community carpet cleaning schedule has been implemented and professional cleaning is scheduled a minimum of monthly.  Care staff to receive training on or before February 22, 2024 on the use of the carpet cleaning equipment available at the community and reporting maintenance concerns. Executive Director or designee will complete a daily walk through of the community a minimum of twice daily 4-5 times weekly by to assure community cleanliness, sanitation, and odor control and maintenance concerns. These walk-throughs will continue as part of standard community operations. 4. Executive Director and Maintenance Director are responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to: Observations from 08/28/23 through 08/31/23 revealed exit doors to the interior courtyards of the Bridge and Clare memory care units failed to have an alarm or other acceptable system to alert staff when residents exited the building. The courtyard doors had an audible alarm which was frequently turned off over the course of the survey. On 08/31/23, the need to ensure exit doors were equipped with an audible alarm or other acceptable system was discussed with Staff 1 (ED). She acknowledged the findings.

Staff has been trained on the interior courtyard door alarm system on 8/29/2023.  Additional alarms placed on the interior courtyard doors The interior courtyard door alarms are checked during community walk through to assure alarm is activated. Community walk through will be completed 4 times a day, 5 days a week, 2 times a day 2 days a week for 60 days at which time this will occur twice a day 5 days a week and 1 time a day 2 days a week. Executive Director or designee is responsible for this plan of correction.

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 150, C 152, C 160, C 200, C 231, C 240, C 242, C 360, C 361, C 513, and C 555.

Refer to plan of correction for C150, C152, C160, C200, C231, C240, C242, C360, C361, C513 and C555.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 150, C 160, C 200, C 231, C 242, C 361, and C 513.

Refer to plan of correction for C 150, C 160, C 200, C 231, C 242, C 361, and C 513.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 361.

see C361

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 243, C 260, C 270, C 280, C 290, and C 340.

Refer to plan of correction for C243, C260, C270, C280, C290, and C340.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 270 and C 280.

Refer to plan of correction for C 270 and C 280

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans, for 6 of 12 sampled residents (#s 3, 5, 7, 8, 9, and 12) and the facility failed to provide a visual contrast between plates, eating utensils, and the table to maximize the independence of each resident. Findings include, but are not limited to: 1. Residents 3, 5, 7, 8, 9, and 12's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. 2. During meal observations, the facility had white plates, white bowls, and white cups on the table. The flatware was silver. There was no visual contrast between plates, eating utensils, and the table to maximize the independence of each resident. The need to develop individualized service plans addressing residents' nutrition and hydration and visual contrast between plates, eating utensils, and the table was discussed with Staff 1 (ED) on 8/30/23. She acknowledged the findings.

Residents 3,5,7,8,9 and 12 service plans have been updated to reflect reported preferences. Table cloths were immediately removed. Contrasting color ordered from vendor on 8/31/2023   Staff has received training in reference to visual contrast between plates, eating utensils and table covering. Weekly upon delivery Executive Director, Dining Director or designee

Based on observation, interview, and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure activity evaluations were completed for 12 of 12 sampled residents (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12's service plans offered some information about the residents' interests, and the facility had not fully evaluated the residents' activity needs in one or more of the following areas: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities which could be used as behavioral interventions, if necessary. There were no resident-specific activity plans developed from activity evaluations which detailed what, when, how, and how often staff should offer and assist the resident with more individualized activities. Observations between 08/28/23 and 08/30/23 showed multiple small group activities being led by facility staff. Residents 1, 7, 9, 11, and 12 were not consistently invited to activities or provided adaptations to participate in the activities. The need to ensure activity evaluations were completed for all residents, from which  individualized activity plans could be developed and consistently implemented to engage residents in meaningful activities, was discussed with Staff 1 (ED) on 08/29/23 and 08/30/23. She acknowledged the findings.

The service plans of resident 1, 2, 3, 5, 7, 8, 9, 11 and 12 have been reviewed by the interdisciplinary team at the community and updated to reflect current needs. A programing skills evaluation has been completed for  current residents. Small group and individual programs have been implemented and staff have received education on the use of this program. Residents' preferences, and needs to engage in activities of interest  will be reviewed by members of the community team to assure that care needs and skills are captured at quarterly review. Executive Director, Health and Wellness Director and Program Coordinator will receive education training on developing individualized activity plans for residents. Service plans will be reviewed quarterly and upon change of condition to ensure that individualized activity plans meet residents' preferences and needs. Executive Director, Health & Wellness Director, Area Health and Wellness Director, Programs Coordinator or designee are responsible for this plan of correction.

Based on observation, interview, and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure activity evaluations were completed for 6 of 6 sampled residents (#s 1, 5, 13, 14, 15 and 17) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: Although Resident 1, 5, 13, 14, 15 and 17's service plans offered some information about the residents' interests, the facility had not fully evaluated the residents' activity needs in one or more of the following areas: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities which could be used as behavioral interventions, if necessary. There were no resident-specific activity plans developed from activity evaluations which detailed what, when, how, and how often staff should offer and assist the resident with more individualized activities. Observations between 01/22/24 and 01/24/24 showed multiple small group activities being led by facility staff in the town square. Residents 1, 5, 13 and 17 were not consistently invited to town square activities or provided adaptations to participate in the activities. No activities within their neighborhood were observed. The need to ensure activity evaluations were completed for all residents, from which individualized activity plans could be developed and consistently implemented to engage residents in meaningful activities, was discussed with Staff 1 (ED), Staff 2 (Area Nurse Manager), Staff 34 (Health & Wellness Director/LPN) and Staff 39 (Area Health & Wellness Director/RN) on 01/23/24 and 01/24/24. They acknowledged the findings.

1. Service plans of the 6 sampled residents (1, 5,13,14,15 and 17) were reviewed and updated to include not just resident interests but skills, abilities, and any adaptation or supports needed to engagement in programs. 2. Service plans will be reviewed to verify that resident preferences, evaluation of skills and abilities, and any adaptations are presen.t 3. Service plans will be reviewed upon move in, change of condition, and quarterly to verify residents have been evaluated for meaningful activities according to their interests, skills, and abilities. 4. Executive Director and Program Coordinator are responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure residents had access to an enclosed, secured outdoor area. Findings include, but are not limited to: Observations of the Clare and Bridge memory care units from 08/28/23 through 08/30/23 revealed interior courtyard doors were frequently locked, preventing residents from entering without staff assistance. On 08/30/23 the need to provide access to secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (ED). She acknowledged the findings.

Staff were re-educated on the interior courtyard door alarm system on 8/29/2023.  Additional alarms were placed on the interior courtyard doors to assure that the violation will not happen again. The interior courtyard door alarms are checked during community walk through to assure alarm is activated. Community walk through will be completed 4 times a day, 5 days a week, 2 times a day 2 days a week for 60 days at which time this will occur twice a day, 5 days a week and 1 time a day, 2 days a week. Executive Director or designee is responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure residents had access to an enclosed, secured outdoor area. This is a repeat citation. Findings include, but are not limited to: Observations of both neighborhoods of the memory care on 01/22/24 showed interior courtyard doors were locked from approximately 10:45 am to 2:30 pm, preventing residents from entering without staff assistance. CG and MT staff interviewed indicated the doors were always kept locked. The need to provide access to secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (ED) on 01/22/24. She acknowledged the findings.

1.Courtyard doors were unlocked during survey. 2. Inclement weather policy was reviewed with staff on January 31, 2024.  Courtyard doors will be unlocked unless outdoor conditions (precipitation, extreme temperatures, etc) are present. Policy was posted for quick reference for staff, visitors, and residents. 3. Courtyard doors will be checked during daytime hours and/or to confirm that the doors are secured or unsecured in keeping with the inclement weather policy.  The check will occur during routine community walk-throughs twice daily 4-5 times each week. 4. Executive Director or designee is responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked outside their rooms. Findings include, but are not limited to: During the survey, observations of resident rooms in Bridge and Clare memory care units revealed rooms were locked from the outside, preventing residents from entering their rooms without assistance from staff. Direct care staff each carried a key which could open all residents' rooms. On 08/30/23, the need to ensure residents were not locked outside their rooms was discussed with Staff 1 (ED). She acknowledged the findings.

Staff has been trained on the interior courtyard door alarm system on 8/29/2023.  Additional alarms were placed on the interior courtyard doors The interior courtyard door alarms are checked during community walk through to assure alarm is activated. Community walk through will be completed 4 times a day, 5 days a week, 2 times a day 2 days a week for 60 days at which time this will occur twice a day 5 days a week and 1 time a day 2 days a week. Executive Director or designee is responsible for this plan of correction

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C 150, C 160, C 200, C 231, C 242, C 270, C 280, C 361, C 513, Z 164, and Z 168.

Refer to plan of correction C 150, C 160, C 200, C 231, C 242, C 270, C 280, C 361, C 513, Z 164, and Z 168.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include but are not limited to: Refer to C 361.

1. We will continue to follow our plan of correction for 361 by submitting bi-weekly reports to the departments as we work on the completion of our ABST approval 2. We will continue to partner with our home office team as well as our partners at DHS to evaluate our current ABST and make any necessary improvements to align with regulatory requirements. 3. We will continue our bi-weekly reporting to the department until we have received DHS approval on our ABST. 4. The Executive Director is responsible for this plan of correction.

The findings of the re-licensure survey, conducted 08/28/23 through 08/31/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with the letter 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 failure of the facility to comply with the Department's rules were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas: OAR 411-054-0025 (8) Facility Administration Records OAR 411-054-0025 (4) Reasonable Precautions OAR 411-054-0027 (1) Resident Rights The facility put immediate plans of correction in place during the survey and the situations were abated.

The findings of the revisit to the re-licensure survey of 08/31/23, conducted 01/22/24 through 01/24/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with the letter 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 A situation was identified where failure of the facility to comply with the Department's rules was likely to cause residents serious harm. An immediate plan of correction was requested in the following areas: OAR 411-054-0025 (4) Reasonable Precautions The facility put an immediate plan of correction in place during the survey and the situation was abated.

The findings of the second revisit to the re-licensure survey of 08/31/24, conducted 04/01/24 through 04/02/24, are documented in this report. The survey was conducted to determine compliance with 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. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 08/31/23, conducted 03/12/25, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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 02/07/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily 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 observation, record review 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 main facility kitchen, butler pantry, food storage areas, food preparation, and food service on 12/6/22 revealed splatters, spills, drips, dust and debris noted on: - Can opener blade and casing; - Floors in dish machine area in between tiles; - Microwave inside surfaces in butler pantry; - Food contact and non food contact surfaces of small diameter thermometer probe; - Inside of drawer in butler pantry; - Butler pantry freezer with spills; * Items found in refrigerator in butler pantry that were not dated (ice cream, milk, sandwich).   * Cutting boards found with deep scoring and staining. * Kitchen staff found not following proper procedures for 3 compartment sink use (not soaking soiled items for correct time, not letting items set/soak in sanitizing solution for required time). * Scoops were found in multiple bulk food storage containers (coffee, flour, sugar, brown sugar, oats). * Kitchen staff observed not washing or sanitizing hands between dirty and clean dish washing tasks. *Person In Charge was not able to verbalize adequate knowledge for:  - correct temperatures (holding/reheating)  - correct method for cooling items;  - correct cooking temperatures for different food items;  - signs and symptoms of food borne illness;  - methods for preventing cross contamination;  - identifying potentially hazardous foods; * the following areas were in need of repair;  - Area missing grout in dish machine area between wall and dish area.  - Large area of tile in dish room noted with missing or damaged grout with visible food and dirt debris noted in between tiles. At approximately 10:15 am, Staff 2 (Dietary Manager) and the Surveyor toured the kitchen. Staff 2 acknowledged the above findings. At 11:00 am the areas in need of cleaning, repair and attention were reviewed with Staff 1 (Executive Director). She acknowledged the findings .

1.*Can opener blade and casing to be cleaned with sanitizer after each use. *Floor grout to be addressed/repaired. *Butler pantry cleanliness to be documented using 10 minute daily audit. Thermometers to be cleaned after each use. * Cutting boards to be replaced. * Scoops have been removed from storage containers. *Grout in dish area repaired/replaced. 2. *Sanitizer will be kept near the can opener. *Floor grout repair has been submitted. *10 minute daily audit will be completed daily. * Sanitizing wipes are present near the therometers. * Replacement cutting boards have been ordered. *All dining staff to receive additional training for proper method of 3 sink washing. * All dining staff to received additional verbal and written instructions for proper hand washing. Dining services coordinator to complete training. 3. Daily during 10 minute audit. 4. The Dining Service Coordinator, Executive Director and/or designee are reponsible for correction and monitorin

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

The findings of the kitchen inspection, conducted 12/6/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 12/6/22, conducted 3/8/23, 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.