Aspen Ridge Memory Care

Based on interview and record review, conducted during a site visit on 08/20/24, it was confirmed the facility failed to develop and implement a written policy prohibiting the falsification of records for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:Staff 1 (RN) stated s/he had worked at the facility for two weeks and was not aware of any altered interim service plans. S/he stated the Compliance Specialist should speak with the Regional Director of Operations. Staff 1 attempted to call the Regional Director of Operations and s/he did not answer.The facility was unable to provide documentation for Resident 5.Adult Protective Services provided LCU with Resident 5's interim service plans, dated 03/19/24, 12/20/24, and 12/24/24.A review of Resident 5's interim service plans, completed by a previous RN, revealed staff signatures had been scanned and copied across all three documents.It was determined the facility failed to implement a written policy that prohibits the falsification of records.The preliminary findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/20/24.

1. Based on interview, and record review, conducted during a site visit on 08/20/24, it was confirmed the facility failed to update service plans quarterly for 2 of 3 sampled residents (#s 2, and 3). Findings include, but are not limited to:Resident 2's care plan, dated 04/09/24, indicated the next evaluation due date was 07/08/24.Resident 3's care plan, dated 04/08/24, indicated the next evaluation due date was 07/07/24.In an interview on 08/20/24 at 1:30 pm, Staff 1 (RN) acknowledged that care plans were out of date and that they were working on updating the care plans with the Resident Care Coordinator. In interviews on 08/20/24, Staff 2 (Bus. Office Mgr.) and Staff 4 (Caregiver) each stated care plans were not being updated quarterly. Residents 2 and 3 were unavailable for interview. The above information was shared with Staff 1 on 08/20/24. S/he acknowledged the findings.It was determined the facility had failed to update service plans quarterly.Verbal Plan of Correction: No plan of correction was provided by the facility.2. Based on observation, interview, and record review, conducted during a site visit on 08/20/24, it was confirmed the facility failed to update service plans quarterly for 2 of 3 sampled residents (#s 2, and 3). Findings include, but are not limited to:Resident 2's care plan, dated 04/09/24, indicated the next evaluation due date was 07/08/24.Resident 3's care plan, dated 04/08/24, indicated the next evaluation due date was 07/07/24.In an interview on 08/20/24 at 1:30 pm, Staff 1 (RN) acknowledged that care plans were out of date and that they were working on updating the care plans with the Resident Care Coordinator. The above information was shared with Staff 1 on 08/20/24. S/he acknowledged the findings. It was determined the facility had failed to update service plans quarterly.Verbal Plan of Correction: No plan of correction was provided by the facility.

Based on observation, interview, and record review, conducted during a site visit on 08/20/24, it was confirmed the facility failed to have direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents. Findings include, but are not limited to:On 08/20/24, upon entering the facility at 12:09 pm, there were no staff at the front desk or in either office. Compliance Specialist (CS) waited in the lobby for over 25 minutes before s/he was acknowledged by staff.The facility's census was 38.The facility's posted staffing plan indicated:Day shift: three caregivers and two med techs;Swing shift: three caregivers and two med techs; andNight shift: two caregivers and one med tech.On 08/20/24, two caregivers and one med tech were observed working the day shift.On 08/20/24, Staff 1 (RN) stated there had been constant staff shortages and the facility did not currently have an administrator for the building. Staff 1 further stated some resident's care needs were not being met timely and care plans were not being updated quarterly.During separate interviews, Staff 2 (Business Office Manager) and Staff 4 (Caregiver) stated there had been constant staff shortages.On 08/20/24 a strong smell of urine was present in the hallway near the nurses station. There was debris and trash on some of the floors, dirty clothes in unsampled resident rooms, beds not made, and trash cans had not been emptied that day. The above information was shared with Staff 1 on 08/20/24. S/he acknowledged the findings. It was confirmed the facility had failed to have qualified direct care staff sufficient in number to meet the 24 hour scheduled and unscheduled needs of residents.Verbal plan of correction: No plan of correction was provided by the facility.

Based on observation, interview, and record review, conducted during a site visit on 08/20/24, it was confirmed the facility failed to fully implement an acuity-based staffing tool (ABST). Findings include, but are not limited to: The facility's posted staffing plan indicated:Day Shift: 3 Caregivers, 2 Med Techs;Swing Shift: 3 Caregivers, 2 Med Techs; andNoc Shift: 2 Caregivers, 1 Med Tech.On 08/20/24, two caregivers and one med tech were observed working the day shift. This did not match the posted staffing plan of three caregivers and two med techs. In an interview on 08/20/24 at 1:30 pm, Staff 1 (RN) stated s/he had started her position a couple of weeks ago and had not had a chance to access the facility's ABST. Staff 1 was unsure what ABST the facility used.During the site visit the facility was unable to access their ABST, despite attempts to contact the Regional Director.A review of the facility's Oregon Department of Human Services ABST on 08/22/24 indicated all 38 residents had been entered into the ABST. The facility's ABST did not match the posted staffing plan.The above information was shared with Staff 1 on 08/20/24. S/he acknowledged the findings. It was confirmed the facility had failed to fully implement an Acuity Based Staffing Tool.

The findings of the Change of Ownership survey, conducted 03/06/24 through 03/08/24, 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 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 03/08/24, conducted 07/08/24 through 07/10/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the second re-visit to the re-licensure survey of 03/08/24, conducted 09/16/24 through 09/18/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the third re-visit to the change of ownership survey of 03/08/24, conducted 03/24/25 through 03/26/25, are documented in this report. The survey was conducted to determine compliance with 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 rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the relicensure survey, conducted 06/02/25 through 06/04/25, are documented in this reported. The relicensure survey was the fourth revisit to the Change of Ownership survey which occurred on 03/08/24. It was determined the facility was in substantial 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 Home and Community Based Services Regulations. Refer to CALMS for relicensure event.

Based on interview and record review, it was determined the facility failed to ensure resident physical altercations were reported to the local SPD office for 1 of 1 sampled resident (#3) who was involved in a physical altercation. Findings include, but are not limited to:Resident 3 was admitted to the facility in June 2023 with diagnoses including dementia. The resident's care plan dated 02/19/24 and interviews with care staff between 03/06/24 and 03/08/24 indicated the resident ambulated independently throughout the facility, would take others food and beverages, and could be intrusive into other residents space. A facility Charting Note dated 02/11/24 indicated Resident 3 took food from another resident's plate. Resident 3 was yelled at and slapped by another resident during the incident.In an interview with Staff 2 (RN) on 03/07/24, she explained the incident had not been reported to the local SPD.The need to ensure physical altercations were immediately reported to the local SPD was reviewed with Staff 1 (Regional Vice President/Interim Administrator) and Staff 2 (RN) on 03/07/24. The staff acknowledged the findings. The facility was asked to report the physical altercation. Confirmation of the report was provided prior to survey exit.
Based on observation, interview, and record review, it was determined the facility failed to ensure resident to resident physical altercations were immediately reported to the local SPD office for 1 of 1 sampled resident (#5), and failed to immediately investigate injuries of unknown cause, document the injuries were not the result of abuse or neglect, and report the incidents to the local SPD office if abuse could not be ruled out for 2 of 2 sampled residents (#s 5 and 6). This is a repeat citation. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 04/2020 with diagnoses including Alzheimer's with agitation.Resident 5 was evaluated to have behaviors of being physically and verbally aggressive with staff during care.In an interview on 07/08/24, Staff 7 (MT) reported Resident 5 had altercations with other residents and was combative with care.During the survey, Resident 5 was observed to walk continuously through the facility halls. The following resident to resident altercations, incidents, and injuries of unknown origin, were documented in facility Charting Notes:*05/11/24 - "Resident was upset, aggressive, and combative... [S/he] grabbed [room number] by the arm and left a mark..."*05/22/24 - "Resident had an outburst of agitation after [his/her] shower. Resident pulled [room number's] hair and slapped [room number's] glasses of [his/her] face."; and*06/19/24 - "Resident was found walking the blood dripping down [his/her] thumb...". For all altercations, staff noted they intervened and re-directed Resident 5.The need to immediately report altercations, ensure injuries and incidents were investigated to rule out abuse or neglect, and reported to the local SPD office if abuse and neglect were not reasonably ruled out, was reviewed with Staff 15 (ED), Staff 16 (Health Service Director RN), Staff 17 (Regional RN), and Staff 19 (RCC) on 07/09/24.The above incidents were reported to the local SPD on 07/09/24.2. Resident 6 was admitted to the facility in 02/2016 with diagnoses including Dementia and Wernicke's Psychosis (memory disorder).Resident 6 was observed to independently mobilize using a wheelchair. Resident 6 had a wound dressing on the left forearm. A facility Charting Note and an Incident Report dated 07/02/24 indicated "Resident being places on alert for a skin tear to [his/her] left forearm..." and "Resident was unaware how skin tear was obtained...".There was no documented investigation to rule out the injury was caused from abuse or neglect. The injury was not reported to the local SPD.The need to ensure injuries and incidents were investigated to rule out abuse or neglect, and reported to the local SPD office if abuse and neglect were not reasonably ruled out, was reviewed with Staff 15 (ED), Staff 16 (Health Service Director RN), Staff 17 (Regional RN) and Staff 19 (RCC) on 07/09/24.The injury of unknown cause was reported to the local SPD on 07/09/24.
Based on observation, interview, and record review, it was determined the facility failed to ensure resident to resident physical altercations were immediately reported to the local SPD office for 1 of 1 sampled resident (#7), and failed to immediately investigate an un-witnessed fall, document the fall was not the result of abuse or neglect, and report the incident to the local SPD office if abuse could not be ruled out, for 1 of 1 sampled residents (#9). This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 02/2024 with diagnoses including dementia.During the survey, Resident 7 was observed to walk continuously through the facility halls, checking doors and colleting items.Facility Charting Notes from 08/17/24 through 09/16/24 were reviewed and staff were interviewed. Resident 7 was noted to have altercations with another resident, resist care, and become combative with staff.On 08/28/24 Charting Notes indicated "....physical altercation occurred in [room number's] apartment. Resident [room number] notified a staff member that [Resident 7] had entered their apartment without consent and was fighting with Resident [room number]. Upon entering apartment discovered Resident [room number] lying on the floor next to [her/his] bed while [Resident 7] was collecting several items off of [Resident room number's] bed...Resident [room number] stated [Resident 7] was going through [his/her] stuff and [s/he] yelled at [him/her] to get out and proceeded to yank [his/her] items from [Resident 7's] hands. [Resident 7] then proceeded to slap resident twice on the left side of [his/her] head causing [him/her] to fall to the floor...".There was no evidence the incident had been reported to the local SPD office. In an interview with Staff 26 (Health Services Director RN) on 09/18/24, she acknowledged the altercation had not been reported.The need to immediately report physical altercations to the local SPD office was reviewed with Staff 1 (Regional Vice President) on 09/18/24. She acknowledged the findings.The above incident was reported to the local SPD on 09/18/24.2. Resident 9 was admitted to the facility in 08/2023 with diagnoses including dementia.During the survey, Resident 9 was observed to utilize a wheelchair with escort for mobility.Facility Charting Notes from 08/17/24 through 09/16/24 were reviewed and staff were interviewed. Staff reported Resident 9 required full assistance with all care and at times required two staff for transfers.On 09/03/24 Charting Notes indicated "...Resident was found laying on [his/her] left side next to [his/her] dresser. Resident stated [s/he] did not hurt [him/herself] when [s/he] fell but did have complaints of all over pain...".There was no documented investigation of the un-witnessed fall that ruled out abuse or neglect. There was no evidence the incident had been reported to the local SPD. In an interview with Staff 26 (Health Services Director RN) on 09/18/24, she acknowledged the incident had not been investigated to rule out abuse or neglect and had not been reported.The need to immediately investigate un-witnessed falls, document the falls were not the result of abuse or neglect, and report the incidents to the local SPD office if abuse could not be ruled out, was reviewed with Staff 1 (Regional Vice President) on 09/18/24. She acknowledged the findings.The above incident was reported to the local SPD on 09/18/24.

Based on interview and record review, it was determined the facility failed to ensure resident to resident physical altercations were immediately reported to the local SPD office for 2 of 2 sampled residents (#s 6 and 10), and failed to immediately investigate, injuries of unknown cause document the incidents were not the result of abuse, or report the injuries to the local SPD office if abuse could not be ruled out, for 2 of 4 sampled residents (#s 10 and 12). This is a repeat citation. Findings include, but are not limited to:1. Resident 6 moved into the facility in 02/2016 with diagnoses including dementia.A progress note written on 03/12/25 identified the resident had a physical altercation with another resident. The incident report, also dated on 03/12/25, had no documented evidence the local SPD office had been notified of the altercation. On 03/24/25 at 4:19 pm, Staff 28 (ED) confirmed the incident had not been immediately reported to the local office. The need to immediately report physical resident to resident altercations to the local SPD office was reviewed with Staff 26 (Health Services Director/RN) and Staff 28 on 03/26/25. They acknowledged the findings.The above incident was reported to the local SPD office on 03/24/25.2. Resident 10 moved into the facility in 10/2023 with diagnoses including dementia. The resident's service plan, dated 03/17/25, Interim Service Plans, progress notes, dated 12/26/24 through 03/24/25, and incident reports, dated 01/26/25 through 03/18/25, were reviewed and the following was identified: a. A progress note written on 03/12/25 identified the resident had a physical altercation with another resident. The incident report, also dated on 03/12/25, had no documented evidence the local SPD office had been notified of the altercation. On 03/24/25 at 4:19 pm, Staff 28 (ED) confirmed the incident had not been immediately reported to the local office. The incident was reported to the local SPD office on 03/24/25.b. Resident 10 was noted to have the following incidents: * 01/26/25: "Resident told staff [s/he] slipped when trying to dress [self]." Resident 10's service plan identified him/her requiring "hands on assistance for dressing";* 02/28/25: "Resident complained of shoulder, neck, and back pain"; and* 03/18/25: "Resident's right side of [his/her] jaw was red and the left side of [his/her] jaw appeared to be swollen" . There was no documented evidence the failure to follow the care plan was reported as neglect to the local SPD nor were the injuries of unknown cause immediately investigated to rule out abuse or reported to the local SPD if abuse could not be ruled out.The above incidents were reported to the local SPD office on 03/25/25. The need to immediately report physical resident to resident altercations, to the local SPD office and to immediately investigate injuries of unknown cause, document the incidents were not the result of abuse, and report the incidents to the local SPD office if abuse could not be ruled out, was reviewed with Staff 26 (Health Services Director/RN) and Staff 28 on 03/26/25. They acknowledged the findings.
3. Resident 12 moved into the facility in 08/2018 with diagnoses including Alzheimer's disease and depression.Resident 12's service plan, dated 01/22/25, progress notes, dated 11/20/24 through 03/22/25, incident reports, and Interim Service Plans were reviewed. The following was identified:The resident experienced unwitnessed, injury falls on 01/02/25 and 02/24/25. Documentation was provided that indicated the incidents were immediately investigated, however the investigations did not reasonably rule out abuse or neglect. On 03/25/25 at 10:16 am, Staff 27 (RCC) confirmed the investigations lacked documentation to rule out abuse or neglect. The resident experienced an additional unwitnessed injury fall on 03/14/25. Documentation indicated the facility did not immediately complete an investigation, did not rule out abuse or neglect, or report the incident to local SPD. On 03/25/25 at 1:29 pm, Staff 26 (Health Services Director/RN) confirmed the incident was not immediately investigated, did not rule out abuse or neglect, and was not reported to local SPD.The facility was asked to report the event to the local SPD office prior to survey exit. Confirmation was received on 03/25/24 at 2:19 pm.The need to investigate injuries of unknown cause immediately and report the incident to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 26 and Staff 28 (ED) on 03/26/25 at 9:45 am. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to:During the survey 03/06/24 through 03/08/24, there was a lack of scheduled and unscheduled activities provided for residents living in the facility.An activity calendar was provided for the community and noted scheduled activities for each day of the week. The only activities observed during the survey were provided by outside visitors on 03/07/24 and included a sing-a-long and an indoor gardening activity. No other scheduled or unscheduled activities were provided or observed during the survey.Residents were observed seated un-engaged in hallways and common areas, wandering the halls, or sitting in front of the TV in the common living room area through the days of the survey.The lack of an activity program was discussed with Staff 1 (Regional Vice President/Interim Administrator). She acknowledged the findings and reported the facility was hiring a new Life Engagement Coordinator.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to:The facility utilized documents labeled Service Plans and Interim Service Plans to direct staff on the care of the residents. The documents were available for staff review in binders located in the charting room and the copy room of the memory care unit. 1. Resident 1 was admitted to the facility in March 2023 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan dated 12/6/23, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * The use of a separated special plate for meals; and* The use of hearing aids. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Regional Vice President/Interim Administrator) and Staff 2(RN) on 03/07/24. The staff acknowledged the findings.2. Resident 2 was admitted to the facility in June 2021 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan dated 03/05/24, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * The use of a separated special plate for meals and a straw for beverages;* Food tracking on a phone application;* Visits to an outside beauty salon;* Sharing a room with a roommate;* The use of a side rail;* The use of hearing aids and glasses;* Inappropriate toileting behaviors; and* Pain issues with ambulation.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Regional Vice President/Interim Administrator) and Staff 2(RN) on 03/07/24. The staff acknowledged the findings.3. Resident 3 was admitted to the facility in June 2023 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan dated 02/19/24, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in relation to Resident 3 smoking marijuana and cigarettes.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Regional Vice President/Interim Administrator) and Staff 2(RN) on 03/07/24. The staff acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were completed quarterly, reflective of residents' needs, readily available to staff, and provided clear direction to staff regarding care and services for 3 of 3 sampled residents (#s 7, 8, and 9) whose service plans were reviewed. Findings include, but are not limited to:The facility utilized documents labeled Service Plans and Interim Service Plans to direct staff on the care of residents. The documents were stored locked in the Med Room and not available to the caregiving staff. 1. Resident 7 was admitted to the facility in 02/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the most current service plan dated 03/29/24, revealed the service plan was not completed quarterly, was not reflective of the resident's current care needs, and did not provide clear direction to staff in the following areas: * Behaviors and interventions;* Denture use; and* Meal assistance. The need to ensure resident service plans were available to staff, completed quarterly, reflective of current care needs, and provided direction to staff was discussed with Staff 1 (Regional Vice President) and Staff 26 (Health Services Director RN) on 09/16/24 and 09/18/24. They acknowledged the findings.2. Resident 8 was admitted to the facility in 04/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the most current service plan dated 05/15/24, revealed the service plan was not completed quarterly, was not reflective of the resident's current care needs, and did not provide clear direction to staff in the following areas: * Fall matt;* Siderails;* Alternating pressure air mattress;* Hospice services;* Behaviors and interventions;* Falls and interventions;* Mobility;* ADL assistance; and* Pain.The need to ensure resident service plans were available to staff, completed quarterly, reflective of current care needs, and provided direction to staff was discussed with Staff 1 (Regional Vice President) and Staff 26 (Health Services Director RN) on 09/16/24 and 09/18/24. They acknowledged the findings.3. Resident 9 was admitted to the facility in 08/2023 with diagnoses including dementia. There was not a printed service plan for Resident 9 in the binders stored in the Med Room. A service plan was printed and provided on 09/16/24.Observations of the resident, interviews with staff, and review of the service plan dated 08/07/24, revealed the service plan was not reflective of the resident's current care needs, and did not provide clear direction to staff in the following areas:* Fall mat;* Mobility;* ADL assistance;* Hospice services provided; and* Fall interventions.The need to ensure resident service plans were available to staff, completed quarterly, reflective of current care needs, and provided direction to staff was discussed with Staff 1 (Regional Vice President) and Staff 26 (Health Services Director RN) on 09/16/24 and 09/18/24. They acknowledged the findings.

4. Resident 11 moved into the facility in 03/2019 with diagnoses including dementia and hypertension.The service plan, dated 03/10/25, was reviewed during the survey. Observations of the resident and interviews with staff were conducted. Resident 11's service plan was not reflective of his/her status and did not provide clear directions regarding the delivery of services in the following areas:* Use of Tubi-grip status on lower extremities; * Use of an air mattress; * Number of staff assistance with dressing/undressing; and* Instructions to staff ensuring the resident dressed appropriately for weather conditions. The need to ensure the resident's service plan was reflective of the resident's current needs and provided clear caregiving instruction was reviewed with Staff 26 (Health Services Director/RN) and Staff 28 (ED) on 03/26/25 at 9:10 am. They acknowledged the findings.
2. Resident 6 moved into the facility in 02/2016 with diagnoses including dementia. The service plan, dated 02/18/25, and Interim Service Plans were reviewed. Observations of the resident were made and interviews with facility staff were conducted. Resident 6's service plan was not reflective of current needs and lacked clear caregiving instruction in the following areas: * Interventions for when the resident refuses incontinent care; * How the resident requested assistance from staff; and * Instructions to staff ensuring the resident dressed appropriately for weather conditions. The need to ensure the resident's service plan was reflective of the resident's current needs and provided clear caregiving instruction was reviewed with Staff 26 (Health Services Director/RN) and Staff 28 (ED) on 03/26/25. They acknowledged the findings. 3. Resident 10 moved into the facility in 10/2023 with diagnoses including dementia. The service plan, dated 03/17/25, and Interim Service Plans were reviewed. Observations of the resident were made and interviews with facility staff were conducted. Resident 10's service plan was not reflective of current needs and lacked clear caregiving instruction in the following areas: * Mental health fluctuations depending on the resident's refusals of medications; * Preference of one on one activities and if s/he does join group activities, where to seat the resident for optimal participation; * Frequency of safety checks being dependant on the residents needs; * Person centered fall interventions; * How to assist Resident 10 with incontinent care to ensure cooperation; and * Instructions to staff ensuring the resident dressed appropriately for weather conditions. The need to ensure the resident's service plan was reflective of the resident's current needs and provided clear caregiving instruction was reviewed with Staff 26 (Health Services Director/RN) and Staff 28 (ED) on 03/26/25. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction regarding the delivery of services, for 4 of 4 sampled residents (#s 6, 10, 11 and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 12 moved into the facility in 08/2018 with diagnoses including Alzheimer's disease and depression. The current service plan, dated 01/22/25, and Interim Service Plans were reviewed, observations were made, and interviews with facility staff were conducted. The following was identified: The resident's service plan lacked resident specific instruction and/or was not reflective of the resident's current status in the following areas: * Fall risk prevention including the use of floor mat;* Instruction for use and safety precautions related to use of hospital bed;* Instruction for use of air pressure mattress;* Repositioning and use of foam cushion for wheelchair;* Instruction relating to transfers;* Instruction and safety precautions for tilting wheelchair use;* Incontinent care including instruction and frequency;* Toileting status; and* Meal assistance that included how the resident communicated if s/he wanted more or was finished with the meal.The need to ensure the resident's service plan provided resident specific instruction and was reflective of the resident's current status, was reviewed with Staff 26 (Health Services Director, RN) and Staff 28 (ED) on 03/26/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's case manager or legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with, or who was going to provide services to the resident, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:The most recent service plans for Residents 1, 2 and 3 were reviewed during the survey. The records lacked documented evidence that the service plans were developed by a service planning team. On 03/07/24, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Regional Vice President/Interim Administrator) and Staff 2 (RN). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate residents with significant changes in condition and monitor the change for 1 of 2 sampled residents (# 2) who experienced wounds. Findings include, but are not limited to:Resident 2 was admitted to the facility in June 2021 with diagnoses including dementia. Resident 2 utilized a wheelchair with staff assistance for all ambulation. Two staff and a mechanical lift were used to transfer Resident 2 in an out of the wheelchair and bed.Resident 2 was observed to receive incontinent care in bed on 03/07/24. The resident has an open wound on the inner aspect of the right buttock. Staff applied barrier cream to the area after providing incontinent care. The resident's 03/05/24 service plan and Charting Notes from 12/07/23 through 03/06/23 were reviewed. A Charting Note dated 02/11/24 indicated "...a small open sore was noted on resident's bottom..."There was no documented evidence of an evaluation of the open wound or weekly monitoring.The need to ensure changes of condition were evaluated, referred to the RN if significant, and monitoring to resolution at least weekly was discussed with Staff 1 (Regional Vice President/Interim Administrator) and Staff 2 (RN) on 03/7/22. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short term changes of condition were monitored weekly until the condition resolved, and residents were monitored per their evaluated needs for 2 of 2 sampled residents (#s 5 and 6) reviewed with changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 04/2020 with diagnoses including Alzheimer's with agitation. Observations of the resident, interviews with staff, and review of the resident's 05/07/24 through 07/08/24 facility Charting Notes were completed. Resident 5 was identified with "...cut to the right thumb..." on 06/19/24.There was no documented evidence the injury was monitored until it resolved.The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly was discussed with Staff 15 (ED), Staff 16 (Health Services Director RN) Staff 17 (Regional RN), and Staff 19 (RCC) on 07/09/24. They acknowledged the findings.2. Resident 6 was admitted to the facility in 02/2016 with diagnoses including Dementia and Wernicke's Psychosis (memory disorder). Observations of the resident, interviews with staff, review of the resident's 06/19/24 evaluation and service plan, 05/07/24 through 07/08/24 facility Charting Notes, and Incident Report and Investigation Worksheets were completed. Resident 6 was evaluated to be at risk for falls and had a history of falls. Charting Notes and incident reports indicated Resident 6 had falls on:*06/30/24 - "Resident was heard screaming for help at 12:20 pm. [S/he] was laying on [his/her] back in [his/her] restroom..";*07/01/24- "Resident is being placed on alert ...appears resident has an un-witnessed fall saying 'I was trying to pick up a banana peel and I leaned too far and ended up falling on my back..."; and*07/07/24 - " Resident found on the floor in [his/her] bathroom..."Resident 6's service plan included interventions to reduce falls. There was no documented evidence the service planned fall interventions were monitored and reviewed to determine effectiveness. The need to ensure residents were monitored per their evaluated needs was discussed with Staff 15 (ED), Staff 16 (Health Services Director RN) Staff 17 (Regional RN), and Staff 19 (RCC) on 07/09/24. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short term changes of condition were monitored weekly until the condition resolved for 3 of 3 sampled residents (#s 7, 8, and 9) and failed to ensure residents were monitored per their evaluated needs for 2 of 2 sampled residents (#s 8 and 9) evaluated with fall risks. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 04/2020 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 08/17/24 through 09/16/24 facility Charting Notes were completed. a. On 08/31/24 Resident 7 was placed on alert charting for "...consuming a piece of dirt that consisted of small bark chips, grass, and dirt. Resident was coughing a lot afterwards and had evidence of dirt on [his/her]bottom teeth..."There was no documented evidence this incident was monitored until it resolved.b. On 9/6/24 Resident 7 was placed on alert charting for starting a new dementia medication. There was no documented evidence the change was monitored to resolution.The need to ensure short-term changes of condition had documentation to reflect weekly monitoring until resolved, was discussed with Staff 1 (Regional Vice President) and Staff 26 (Health Services Director RN) on 09/18/24. They acknowledged the findings.2. Resident 8 was admitted to the facility in 04/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 08/17/24 through 09/16/24 facility Charting Notes were completed. Staff reported Resident 8 currently had bruising on the right hip resulting from a fall.Resident 8 was identified to be at risk for falls and had a history of falls. Charting Notes, Interim Service Plans, and incident reports indicated Resident 8 was found on the floor in a common hallway on 08/26/24.Resident 8 was noted with complaints of pain and reported hitting his/her head.There was no documented evidence the Resident 8's fall was evaluated, interventions developed, communicated to staff, and monitored for effectiveness. There was no evidence Resident 8's pain and injuries were monitored to resolution. The need to ensure residents were monitored per their evaluated needs and the need to ensure short-term changes of condition had documentation to reflect weekly monitoring until resolved, was discussed with Staff 1 (Regional Vice President) and Staff 26 (Health Services Director RN) on 09/18/24. They acknowledged the findings.3. Resident 9 was admitted to the facility in 08/2023 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 08/17/24 through 09/16/24 facility Charting Notes were completed. a. Resident 9 was identified to be at risk for falls and had a history of falls. Charting Notes, Interim Service Plans, and incident reports indicated Resident 9 was found on the floor on:* 08/23/24 - Resident found on floor in apartment with "...egg sized bump to the lower back of [his/her] head...".; and* 09/03/24 - Resident found on floor in apartment with "...complaint of all over pain..."There was no documented evidence Resident 9's falls were evaluated, interventions developed, communicated to staff, and monitored for effectiveness.There was no evidence Resident 9's injury and pain were monitored to resolution. The need to ensure residents were monitored per their identified risks, and the need to ensure short-term changes of condition had documentation to reflect weekly monitoring until resolved, was discussed with Staff 1 (Regional Vice President) and Staff 26 (Health Services Director RN) on 09/18/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and to monitor the change of condition, at least weekly, until resolved for 4 of 4 sampled residents (#s 6, 10, 11 and 12) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 11 moved into the facility in 03/2019 with diagnoses including dementia and hypertension.The resident's clinical record including progress notes, dated 12/11/24 through 03/24/25, service plan, dated on 03/10/25, and Interim Service Plans (ISP's) were reviewed during the survey. The facility failed to monitor the changes of condition, at least weekly, until resolved for the following: * 12/28/24: New medication started, oxycodone for pain;* 01/11/25: New medication started, Lasix (diuretic) for edema; and* 01/21/25 and 02/19/25: Increased dose of Lasix for edema.The need to ensure the facility monitored changes of condition, at least weekly, until resolved was discussed with Staff 26 (Health Services Director, RN) and Staff 28 (ED) on 03/26/25 at 9:10 am. They acknowledged the findings.
3. Resident 6 moved into the facility in 02/2016 with diagnoses including dementia.The resident's service plan, dated 02/18/25, Interim Service Plans, and progress notes, dated 12/18/24 through 03/18/25, were reviewed and the following was identified: On 03/12/25, Resident 6 had a physical altercation with another resident. There was no documented evidence resident specific actions or interventions were determined and communicated to staff on each shift to prevent further altercations. The need to ensure the facility determined and documented what action or intervention was needed for the resident, the determined action or intervention was communicated to staff on each shift, and the documentation of staff instructions or interventions were resident specific when a resident experienced a change of condition was discussed with Staff 26 (Health Services Director, RN) and Staff 28 (ED) on 03/26/25. They acknowledged the findings.4. Resident 10 moved into the facility in 10/2023 with diagnoses including dementia.The resident's service plan, dated 03/17/25, Interim Service Plans (ISPs), and progress notes, dated 12/16/24 through 03/24/25, were reviewed and the following changes of condition were identified: * Multiple dates of refused or missed medications; * Six falls between 12/29/24 and 03/18/25; * 02/10/25: Weight increase of 15 pounds in 16 days; * 03/12/25: Resident to resident altercation; * 03/17/25: Antibiotic started; and * 03/21/25: Small skin abrasion on left shoulder. There was no documented evidence the facility determined and documented what action or intervention was needed for Resident 10, the determined action or intervention was communicated to staff on each shift, and/or the documentation of staff instructions or interventions were resident specific. The need to ensure the facility determined and documented what action or intervention was needed for the resident, the determined action or intervention was communicated to staff on each shift, and the documentation of staff instructions or interventions were resident specific when a resident experienced a change of condition was discussed with Staff 26 (Health Services Director, RN) and Staff 28 (ED) on 03/26/25. They acknowledged the findings.
2. Resident 12 moved into the facility in 08/2018 with diagnoses including Alzheimer's disease and depression.The resident's clinical record, including the service plan, dated 01/22/25, observation and progress notes, dated 11/20/24 through 03/22/25, and Interim Service Plans were reviewed. The following was identified: The facility failed to monitor the change of condition, at least weekly, until resolved for the following: * 01/26/25: "possible mini-stroke";* 02/24/25: unwitnessed injury fall;* 03/14/25: unwitnessed injury fall; and* Weight loss. The need to ensure the facility monitored the change of condition, at least weekly, until resolved was discussed with Staff 26 (Health Services Director, RN) and Staff 28 (ED) on 03/26/25 at 9:45 am. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a RN assessment was completed for significant changes in condition, including findings and resident status as a result of the assessment, for 2 of 2 sampled residents (#s 2 and 3) who experienced open wounds. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in June 2021 with diagnoses including dementia and was dependent for all care needs.Resident 2's record revealed s/he was identified with an open wound to the buttock on 02/11/24.There was no evidence of a RN assessment of Resident 2's open wound, a significant change in condition.The need to ensure significant changes in condition were assessed timely and included findings and resident status was reviewed with Staff 1 (Regional Vice President/Interim Administrator) and Staff 2 (RN) on 03/07/24 and 03/08/24. They acknowledged the findings.2. Resident 3 was admitted to the facility in June 2023 with diagnoses including dementia and insulin dependent diabetes.Resident 3's record revealed s/he was identified with an open wound to the ball of the right foot on 01/18/24. There was no evidence of a RN assessment of Resident 3's open wound, a significant change in condition.Home Health services were initiated and a Charting Note dated 02/22/24 indicated the wound was calloused over.The need to ensure significant changes in condition were assessed timely and included findings and resident status was reviewed with Staff 1 (Regional Vice President/Interim Administrator) and Staff 2 (RN) on 03/07/24 and 03/08/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain effective infection prevention and control protocols to provide a safe, sanitary, and comfortable environment. Findings include, but are not limited to:On 03/25/25, observations of lunch service were conducted and identified Staff 38 (CG) and Staff 41 (CG), who provided hand over hand assistance for Resident 11 during dining services, did not perform hand hygiene in between assisting Resident 11 and two unsampled residents who required hand over hand assist and/or cueing during lunch service. Multiple caregivers were observed to serve residents lunch and touch residents and their chairs and/or wheelchairs, cuing and providing assistance to initiate intake, refill resident beverages, and remove dirty dishes without performing hand hygiene in between dirty and clean tasks or before assisting other residents. The need to ensure infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was reviewed with Staff 26 (Health Services Director, RN) and Staff 28 (ED) on 03/26/25 at 9:45 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 3 sampled residents (#s 10 and 12) whose orders were reviewed. Findings include, but are not limited to:1. Resident 10 moved into the facility in 10/2023 with diagnoses including dementia. The resident's 02/2025 MAR, progress notes, dated 02/04/25 through 03/23/25, and physician's orders were reviewed. The following medications were not administered per physician's orders as staff documented that Resident 10 was sleeping: * Quetiapine (for behaviors): Eight times;* Pantoprazole (for heartburn): Eight times;* Tramadol (for pain): Thirteen times;* Ferrous gluconate (for iron supplement): Nine times; * Cephalexin (an antibiotic): Three times; and * Simvastatin (for lowering cholesterol): Once.The need to ensure physician's orders were carried out as prescribed was reviewed with Staff 26 (Health Services Director/RN) and Staff 28 on 03/26/25. They acknowledged the findings.
2. Resident 12 moved into the facility in 08/2018 with diagnoses including Alzheimer's disease and depression.The resident's record, including current physician orders, dated 02/19/25, and MARs, dated 02/01/25 through 03/24/25, were reviewed and identified the following:Resident 12 had an order for the facility to administer acetaminophen (for pain) three times daily, however the order was transcribed to the MAR to be administered as needed. On 03/26/25 at 8:58 am, orders were reviewed with Staff 26 (Health Services Director, RN) and documentation of a reflective order was requested. No additional documentation was provided. The need to ensure signed physician orders were administered as ordered, was reviewed with Staff 26 and Staff 28 (ED) on 03/26/25 at 9:10 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to an order, for 1 of 1 sampled resident (#1) with multiple medication refusals. Findings include, but are not limited to:Resident 1 was admitted to the facility in 03/2023 with diagnoses including dementia, high blood pressure, and cardiac issues. Resident 1's MARs from 02/01/24 through 03/06/24 were reviewed. Resident 1 refused some or all medications and treatments for 23 days in February 2024 and on six days in March 2024.In an interview with Staff 4 (MA) on 03/07/04, she reported Resident 1 often refused medications and the physician should be faxed.There was no documented evidence each incident of Resident 1's multiple medication refusals had been reported to the practitioner. The facility's failure to notify the practitioner when Resident 1 refused ordered medications or treatments was reviewed with Staff 1 (Regional Vice President/Interim Administrator) and Staff 2 (RN) on 03/07/24. They acknowledged the physician had not been informed of the refusals.
Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to an order for medication administration for 1 of 1 sampled resident (# 10) who was reviewed with documented refusals. Findings include, but are not limited to:Resident 10 moved into the facility in 10/2023 with diagnoses including dementia. The resident's MARs, dated 02/01/25 through 03/24/25, progress notes, dated 02/04/25 through 03/23/25, and physician's orders were reviewed. The resident refused multiple medications, including an antibiotic and a medication used to treat behaviors, on the following dates: * 02/21/25;* 02/22/25;* 03/01/25;* 03/02/25;* 03/06/25;* 03/08/25;* 03/09/25;* 03/14/25; * 03/17/25; * 03/21/25; and* 03/22/25: Relating to the evening administration. There was no documented evidence the facility notified the physician each time the resident refused consent to the orders. The need to ensure the facility notified the physician of medication refusals was reviewed with Staff 26 (Health Services Director/RN) and Staff 28 (ED) on 03/26/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included reason for use, resident-specific parameters, and staff instruction for 2 of 3 sampled residents (#s 10 and 11) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 11 moved into the facility in 03/2019 with diagnoses including dementia and hypertension.Resident 11's 03/01/25 through 03/24/25 MARs were reviewed during the survey and the following was identified:* Multiple PRN bowel care medications lacked clear parameters for when they should be administered, and which one should be given first; and* Multiple PRN secretion medications lacked clear parameters for when they should be administered, and which one should be given first. On 03/26/25 at 9:10 am, the need for resident-specific parameters and clear instructions for unlicensed staff was discussed with Staff 26 (Health Services Director, RN) and Staff 28 (ED). They acknowledged the findings.
2. Resident 10 moved into the facility in 10/2023 with diagnoses including dementia. The resident's 02/2025 MAR was reviewed and the following medications lacked a reason for use: * Ferrous gluconate;* Pantoprazole;* Quetiapine; and * Tramadol.The need to include reasons for use for all medications was discussed with Staff 26 (Health Services Director, RN) and Staff 28 (ED) on 03/26/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were given only for specific medical symptoms and only after non-drug interventions had been attempted and were ineffective, for 1 of 1 sampled resident (# 11) who had an order for PRN psychoactive medication. Findings include, but are not limited to:Resident 11 moved into the facility in 03/2019 with diagnoses including dementia and hypertension.Resident 11's 03/01/25 through 03/24/25 MARs were reviewed during the survey and revealed the following:* The resident had an order for Ativan 0.5 mg, give one tablet by mouth every two hours as needed for agitation;* The PRN Ativan was administered on 27 occasions;* Non-drug interventions were documented for staff to try prior to the administration on the Resident 11's MAR; and* There was documentation that non-drug interventions had been attempted with ineffective results prior to administering the medication on multiple occasions.On 03/26/25 at 9:10 am, Resident 11's record was reviewed with Staff 26 (Health Service Director, RN) and Staff 28 (ED) and the need to attempt non-drug interventions and document as ineffective prior to administration was discussed. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to develop a staffing plan to meet the scheduled and unscheduled needs of the residents based on care minutes calculated by their ABST tool. Findings include, but are not limited to:The facility's ABST tool calculations and the facility's staffing plan were reviewed on 09/18/24.The facility had a census of 33 residents in the building on 09/16/24.Review of the staffing plan generated by the ABST indicated a need for 15 staff in a 24 hour period.The staffing plan/schedule revealed:* 09/15/24 - 12 staff had been scheduled;* 09/16/24 - 11 staff were scheduled, one staff did not come to work, ten staff actually worked;* 09/17/14 - 12 staff were scheduled to work; and* 9/18/24 - 14 staff were scheduled to work. The need to ensure ABST staffing calculations were used to develop and implement a staffing plan to meet resident needs was discussed with Staff 1 (Regional Vice President) on 09/18/24. Staff 1 acknowledged the staffing schedule did not been the ABST generated staffing plan.

2. Resident 11 moved into the facility in 03/2019 with diagnoses including dementia and hypertension.The service plan, dated 03/10/25, Interim Service Plans, and the resident's corresponding ABST individual minutes were reviewed. The resident was observed and interviews were conducted with staff. The resident's care time and care elements were found to not be reflective in the following areas:* Leisure activities;* Non-drug interventions for behaviors;* Providing treatments; and * Bathing/shower.The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 26 (Health Services Director, RN) and Staff 28 (ED) on 03/26/25 at 9:10 am. They acknowledged the findings.
3. Resident 6 moved into the facility in 02/2016 with diagnoses including dementia.The service plan, dated 02/18/25, Interim Service Plans, and the resident's corresponding ABST individual minutes were reviewed. The resident was observed and interviews were conducted with staff. The resident's care time and care elements were found to not be reflective in the following areas:* Monitoring behavioral conditions or symptoms; and * Assistance needed with dressing and undressing. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 26 (Health Services Director, RN) and Staff 28 (ED) on 03/26/25. They acknowledged the findings.4. Resident 10 moved into the facility in 10/2023 with diagnoses including dementia.The service plan, dated 03/17/25, Interim Service Plans, and the resident's corresponding ABST individual minutes were reviewed. The resident was observed and interviews were conducted with staff. The resident's care time and care elements were found to not be reflective in the following areas:* Non-drug interventions for behaviors; * Safety checks and fall prevention; and* Bowel and bladder management. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 26 (Health Services Director, RN) and Staff 28 (ED) on 03/26/25. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 4 of 4 sampled residents (#s 6, 10, 11, and 12) whose ABST was reviewed. Findings include, but are not limited to: 1. Resident 12 moved into the facility in 08/2018 with diagnoses including Alzheimer's disease and depression.The service plan, dated 01/22/25, Interim Service Plans, and the resident's corresponding ABST individual minutes were reviewed. The resident was observed and interviews were conducted with staff. The resident's care time and care elements were found to not be reflective in the following areas:* Providing treatments;* Repositioning in bed or chair;* Transferring in and out of bed or chair; and* Dressing and undressing.The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 26 (Health Services Director, RN) and Staff 28 (ED) on 03/26/25 at 9:45 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 7, 8 and 9) had documented evidence of training in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 03/07/24 and 03/08/24. Staff 8 (CG) and Staff 9 (CG), hired on 01/03/24 and 01/08/24 respectively, lacked documented evidence they had completed abdominal thrust training within 30 days of hire. Staff 7 (MT), hired 01/1/24, lacked documented evidence being trained in First Aid and abdominal thrust within 30 days of hire. The need to ensure staff completed the required training within 30 days was reviewed with Staff 1 (Regional Vice President/Interim Administrator) on 03/08/24. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired direct care staff (#s 20 and 22) had documented evidence of training in First Aid and abdominal thrust within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 07/09/24 and 07/10/24. Staff 20 (CG) and Staff 22 (CG), hired on 05/09/24 and 05/28/24 respectively, lacked documented evidence they had completed First Aid and abdominal thrust training within 30 days of hire. The need to ensure staff completed the required training within 30 days was reviewed with Staff 15 (ED) and Staff 18 (Business Office Manager) on 07/09/24 and 07/10/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 31, 34, 35) had documented evidence of training in First Aid and abdominal thrust within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 09/18/24. Staff 31 (CG), hired 08/14/24, Staff 34 (CG), hired on 08/07/24, and Staff 35 (CG), hired 08/12/24, lacked documented evidence they had completed First Aid and abdominal thrust training within 30 days of hire. The need to ensure staff completed the required training within 30 days was reviewed with Staff 1 (Regional Vice President). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire and life safety training at least every other month. Findings include, but are not limited to:Fire and life safety records, reviewed between 08/2024 - 03/2024, revealed fire and life safety training was not documented as completed every other month alternating with fire drills.On 03/07/24 the need provide fire and life safety training was reviewed with Staff 1 (Regional Vice President/Interim Administrator). She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C231, C270, C372, Z142, Z155, and Z164.
Based on observation, interview, and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 231, C 270, C 372, and Z 155.

Based on observation, interview, and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 231, C 260, C 270, and Z 155.

Based on observation and interview, it was determined the facility failed ensure the doors that exited to courtyards were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:The facility was observed with three secured courtyards. On 09/16/24, the door exiting to the center courtyard from the TV room, and the door exiting to the north courtyard from the events room had no alarm or other acceptable system to alert staff when residents entered or exited the facility. The failure to ensure doors were equipped with an alarming device or other systems to alert staff was discussed with Staff 1 (Regional Vice President) on 06/16/24. She acknowledged the findings. The south courtyard door was alarming on 09/18/24. The TV room courtyard door was not alarming on 09/18/24. Staff were conducting 30 minute checks of the courtyards.

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 Refer to C 231, C 242, C 372, and C 420.
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 Refer to C231 and C372.
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 Refer to C 231, C 361, C 372, and C 555.

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 Refer to C 231 and C 295.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 7, 8, and 9) had signed written job descriptions, completed all pre-service orientation and training, and had documentation of demonstrating competency in all required areas within 30 days of hire. The facility failed to ensure 3 of 3 sampled long term care staff (#s 5, 11, and 12) completed 16 hours of annual in-service training, including dementia care and infection control. The facility failed to ensure 2 of 2 non-care staff (#s 10 and 14) completed annual infection control training. Findings include, but are not limited to:Staff training records were reviewed on 03/07/24 and 03/08/24.a. Staff 7 (MT), hired 01/01/24, Staff 8 (CG), hired 01/03/24, and Staff 9 (CG), hired 01/08/24, did not have signed job descriptions, and lacked documented evidence of completing all pre-service orientation and training requirements including Fire safety and emergency procedures and the use of devices with restraining qualities in a MCC. Staff 7 (MT), Staff 8 (CG), and Staff 9 (CG) lacked documented evidence of demonstrating competence in all job duties within 30 days. Staff 7 lacked evidence of demonstrating competence with medication pass. Staff 1 (Regional Vice President/Interim Administrator) and Staff 2 (RN) agreed Staff 7 would not pass medications until she had demonstrated competence. b. Staff 11 (CG), hired 9/25/21, Staff 12 (CG) hired 03/05/2023, and Staff 5 (MT), hired 05/24/19, lacked evidence of 16 hours of annual in-service training, including six hours related to dementia care and annual infectious disease training, based on anniversary of hire dates. c. Staff 14 (Housekeeper), hired 01/01/13 and Staff 10 (Lifestyle Assistant/MT), hired 04/09/19, lacked evidence of completing annual training on infectious disease outbreak and infection control based on anniversary date of hire. The need to ensure staff signed written job descriptions, completed all pre-service orientation, demonstrated competence in all job duties within 30 days, and completed annual training including dementia care and infection control, was discussed with Staff 1 (Regional Vice President/Interim Administrator) on 03/08/24. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired staff (#s 20, 21, 22, and 23) had completed all pre-service orientation and training and had documentation of demonstrating competency in all required areas within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 07/09/24 and 07/10/24.Staff 20 (CG), hired 05/09/24, Staff 21 (CG), hired 05/28/24, Staff 22 (CG), hired 05/28/24, and Staff 23 (MT), hired 05/06/24, lacked documented evidence of completing some or all of the pre-service orientation and training requirements, including:*Resident rights and values of CBC care;*Abuse reporting requirements;*Fire safety and emergency procedures;*Infectious Disease Prevention;*Home and Community Based Services;*Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;*Techniques for understanding, communicating and responding to distressful behavioral symptoms;*Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;*Environmental factors that are important to a resident's well-being;*Family support and the role the family may have in the care of the resident;*How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; *How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and*Use of supportive devices with restraining qualities in memory care communities.Staff 20 (CG), Staff 21 (CG), Staff 22 (CG), and Staff 23 (MT) lacked documented evidence of demonstrating competence in all job duties within 30 days. The need to ensure staff completed all pre-service orientation and demonstrated competence in all job duties within 30 days was discussed with Staff 15 (ED) and Staff 18 (Business Office Manager) on 07/09/24 and 07/10/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 31, 34, 35, and 36) completed all required pre-service orientation and dementia training, and failed to ensure 3 of 3 newly hired staff (#s 31, 34, and 35) demonstrated competence in all job duties with 30 days. This is a repeat citation. Findings include, but are not limited to:Training records for Staff 31 (CG), hired 08/14/24, Staff 34 (CG), hired on 08/07/24, Staff 35 (CG), hired 08/12/24, and Staff 36 (CG), hired 08/26/24, were reviewed on 09/18/24.1. There was no documented evidence the staff had completed pre-service orientation and the required dementia training prior to performing any job duties, including:* Resident rights;* Abuse reporting requirements;* Fire safety and emergency procedures;* Infectious Disease Prevention;* Home and Community Based Services course;* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;* Techniques for understanding, communicating and responding to distressful behavioral symptoms;* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;* Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.);* Family support and the role the family may have in the care of the resident;* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and* Use of supportive devices with restraining qualities in memory care communities.2. There was no documented evidence Staff 31 and 34 demonstrated competency in their job duties within 30 days of hire in the following areas:* The role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting;and* General food safety, serving and sanitation.3. There was no documented evidence Staff 35 demonstrated competency in their job duties within 30 days of hire in the following areas:* Changes associated with normal aging; and* General food safety, serving and sanitation.The facility's failure to ensure staff completed all required pre-service orientation and training, and demonstrated competence in job duties, was discussed with Staff 1 (Regional Vice President). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 38, 40, 43, and 44) completed all required pre-service dementia training and demonstrated competence in all job duties with 30 days. This is a repeat citation. Findings include, but are not limited to:The facility's training records for Staff 38 (CG/MT), hired 01/03/25, Staff 40 (CG/MT), hired on 01/03/25, Staff 43 (CG), hired 01/13/25, and Staff 44 (CG), hired on 01/02/25, were reviewed on 03/25/25.1. There was no documented evidence Staff 38, 40, 43, and 44, had completed the required pre-service dementia training, including the topics of:* Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.);* Family support and the role the family may have in the care of the resident;* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and* Use of supportive devices with restraining qualities in memory care communities.2. There was no documented evidence Staff 38, 40, 43, and 44 demonstrated competency in their job duties within 30 days of hire in the following areas:* Conditions that require assessment, treatment, observation and reporting; and* Staff 38 and 40 lacked documented medication administration competency.On 03/25/25 at 10:00 am, survey requested Staff 38 and 40 be removed from administering medications until medication competency could be verified and documented for the sampled staff. The facility's failure to ensure staff completed all required pre-service dementia training and demonstrated competence in job duties were discussed with Staff 28 (ED) on 03/25/25 at 10:00 am. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 260, C 262, C 270, C 280, and C 305.
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 C270.
Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 260 and C 270.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 260, C 270, C 303, C 305, C 310, C 330, and C 362.

Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked outside their rooms, and the facility failed to individually identify rooms to assist residents in recognizing their room. Findings include, but are not limited to:1. During the survey, observations of multiple resident rooms revealed they were locked from the outside, preventing residents from entering their rooms without assistance from staff. Caregiving staff each carried a key which could open all residents' rooms. Several residents were noted waiting outside their homes waiting for and requesting assistance to enter on multiple occasions.Room 204 locked automatically and lacked a mechanism to unlock it with out a key. It opened freely from the inside. On 09/18/24, the need to ensure residents were not locked outside their rooms was discussed with with Staff 1 (Regional Vice President). She acknowledged the findings.2. The facility was toured on 09/16/24 through 09/18/24. Occupied resident rooms 101, 105, 110, 202, and 302 lacked any individually specific means of identifying the room for the residents. All other rooms were identified with laminated papers with resident first names and last initials.The need to ensure each resident room was identified to assist the resident in identifying their room was reviewed with Staff 1 (Regional Vice President). She acknowledged the findings.

The findings of the kitchen inspection, conducted 05/18/23, 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.

Based on observation, interview, and record review, 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 kitchen, food storage, prep, and service on 05/18/23 revealed:Spills, splatters, and debris were noted:* The sides, front, and interior of the range;* Interior of drawers throughout the kitchen;* The open shelving and shelving legs throughout the kitchen; * The can opener blade and casing;* Rack shelving throughout the kitchen;* Rack shelving in the walk in refrigerator;* Appliances including stand mixers, blenders, and food processor;* Surfaces of food bins in dry storage;* Dishwashing area equipment and flooring;* Floor throughout the kitchen.* Staff 2 (Sous Chef) explained the facility used auto dispense Quaternary solution for the sanitizer buckets. There was no documented evidence it was monitored to ensure the correct solution. The sanitizer bucket was tested and found to be at the required part per million.* Food items in the walk in refrigerator not dated or labeled.* Boxes of food were stored on the floor in the walk in freezer.* Multiple packaged food items were not dated when opened.* A dented can was noted in the dry storage.* Styrofoam cup left in bulk bin of food.* The back door of the kitchen was left propped open allowing for the entry of pests.* Caregiving staff did not don aprons while serving food to residents. The areas in need of cleaning, food storage guidelines, and infection control were reviewed with Staff 1 (Executive Director) and Staff 2 on 05/18/23. They acknowledged the findings.

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

The findings of the kitchen inspection, conducted 07/19/22, 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 07/19/22, conducted 10/24/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, record review and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchen, food storage areas, food preparation, and food service on 07/19/22 revealed:* Splatters, spills, drips and debris noted on: - Hand washing sink and wall; - Bins of food in dry storage and prep area; - Radio in the prep area; - Shelving throughout kitchen; - Baking pans; - Can opener casing and blade; - Exterior and interior of drawers; - Carts; - Fryer; - Sides and behind range; and - Stand mixers.* Undated, unlabeled, and uncovered foods were observed in the walk in refrigerator;* Boxes were stored on the floor in the walk in freezer; and* Bins of food were noted with cups and scoops left in the foods. The food storage concerns and areas in need of cleaning were reviewed with Staff 1 (Director of Memory Care) and Staff 2 (Sous-Chef). They acknowledged the findings.

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

The findings of the re-licensure survey, conducted 10/14/21 through 10/15/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 10/15/2021, conducted on 1/24/2022, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OAR's 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure incidents of suspected abuse were immediately reported to the local SPD office for 2 of 2 sampled residents (#s 3 and 4) reviewed with resident to resident altercations, and failed to immediately investigate injuries of unknown cause and document the injuries were not the result of abuse or report the injury to the local SPD office as suspected abuse for 1 of 1 sampled residents (#3) who had injuries of unknown cause. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 07/2021 with diagnoses including dementia and anxiety.Resident 4 was evaluated to have behaviors of being intrusive with other residents. Interventions were developed and included in the service plan.In interviews with caregiving staff, they reported Resident 4 was unaware of social boundaries and was intrusive and aggressive at times. The following resident to resident altercations, incidents, and injuries of unknown origin were documented in facility Charting Notes:*07/17/21 - "Resident being placed on alert due to altercations with resident in [room number]. Residents were yelling at one another and [Resident 4 name] attempted to swat resident in [room number] hitting [his/her] hand...";*07/22/21 - "...Altercation between [resident room number] and [Resident 4] at approximately 1910...[Resident 4] approached [resident room number] and grabbed at [his/her] walker which resulted in [resident room number] smacking [Resident 4] on the [left] arm...";*07/26/21 - ..."[Resident room number] was entering the building from the courtyard when [Resident 4] approached and grabbed [resident room number] arm and then began to strike [him/her]. A few minutes prior [resident room number/Resident 4] had an unwitnessed altercation...";*07/27/21 - "[Resident room number] was walking down the hall when [Resident 4] reached out [his/her] hand and struck [resident room number] with an open hand. [Resident room number] stated "why"...";*08/04/21 - "Resident was discovered in the courtyard on the facility at 04:40 after a brief search of the premises. Resident was found laying in the dirt next to the building after being outside for an unknown amount of time...";*08/06/21 - "...Altercation with roommate. [Resident 4] was seen having his/her head pushed against the wall...;*08/10/21 - "Resident is being placed on alert due to scratches on the back of left arm. Scratches appear to be scabbing and originated from resident being outside all night. There are many small scratches in a patch about the size of a palm on the left arm...";*08/10/21 - "Resident is being placed on alert due to bruising to the back of left and right arms. Bruises are a light green/purple in coloration and about the size of baseballs...";*08/12/21 - "Resident is being placed on alert due to physical altercation with [resident room number]...[Resident 4] touched his beard and he slapped [his/her] hand away...";*09/14/21 - "Resident being placed on alert...An unusually large bruise...located on left buttock and goes from left cheek down about half way to the back of the knee. Roughly 1 1/2 foot by 4 inches...";*10/11/21 - "Resident being placed on alert [due to] altercation between [him/her] and [resident room number]. Resident was walking towards [resident room number] and noticed [his/her] jacket, so [s/he] tried pulling it off[him/her]. [Resident room number] grabbed [Resident 4's] arm..."; and*10/12/21 - "Resident being placed on alert [due to] nickel sized bruise being found on the back right side of [his/her] head..." For all altercations, staff noted they intervened and re-directed Resident 4.The need to ensure injuries and incidents were investigated to rule out abuse or neglect, and reported to the local SPD office if abuse and neglect were not reasonably ruled out, was reviewed with Staff 1 (ED) and Staff 16 (Corporate Operations) on 10/14/21.In an interview with Staff 1 on 10/14/21, evidence the incidents of resident to resident altercations were reported to the local SPD office was requested. Staff 1 stated the incidents had not been reported. Staff 1 immediately reported all of the resident to resident altercations, injuries of unknown origin, and incident of being on the ground in the courtyard for an unknown amount of time.
2. Resident 3 was admitted to the facility in 07/2021 with a diagnoses including dementia.Review of Resident 3's facility Charting Notes dated 07/16/21 through 10/13/21 revealed:a. Resident 3 was involved in a physical resident to resident altercation on 07/24/21. There was no documented evidence the facility reported the altercation to their local SPD office.Staff 1 (ED) said he would report the incident to SPD on 10/15/21. The surveyor received confirmation this incident was reported on 10/15/21.b. On 08/03/21, Resident 3 was found on the floor in his/her room and had a bloody nose. S/he complained of pain in his/her left shoulder and chest. The facility called Emergency Medical Services to transport him/her to the hospital. There was no documented evidence the injury of unknown cause on 08/03/21 had been reported to SPD or an immediate investigation was completed to reasonably rule out abuse.The need to ensure resident incidents are thoroughly investigated in a timely manner, reported to the local SPD office and investigate injuries of unknown origin was discussed with Staff 1 and Staff 16 (Corporate Operations) on 10/15/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the kitchen on 10/14/21 through 10/15/21 showed the following:* Dented cans located in the pantry;* Multiple undated opened items in the refrigerator;* Top of the dishwasher had dried white and black substance;* Walls under triple wash sink had black and yellow substance;* Wall next to coffee machine had dried food stains;* Lid to deep fryer had food debris on it; and* Frozen meat was thawing on a middle shelf in the refrigerator in plastic wrap not on a tray. The need to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (ED), Staff 16 (Corporate Operations) and Staff 7 (Executive Chef) on 10/14/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to document monitoring of residents consistent with their evaluated needs for 3 of 4 sampled residents (#s 2, 3 and 4) who experienced falls. Findings include but are not limited to:1. Resident 2 was admitted to the facility in 11/2018 and evaluated as a fall risk.Resident 2's service plan included interventions to reduce falls. Resident 2's facility Charting Notes and Incident Report and Investigations Worksheets for 07/2021 through 10/14/21 revealed two falls on 09/20/21 resulting in a hospital stay.There was no documented evidence the service planned fall interventions were monitored and reviewed to determine effectiveness. The need to monitor residents per their evaluated needs was discussed with Staff 1 (ED). He acknowledged the findings.2. Resident 4 was admitted to the facility in 07/2020 and evaluated as a fall risk.Resident 4's service plan included interventions to reduce falls. Resident 4's facility Charting Notes and Incident Report and Investigations Worksheets for 07/2021 through 10/14/21 revealed Resident 4 had falls or incidents of being found on the ground four times.There was no documented evidence the service planned fall interventions were monitored and reviewed to determine effectiveness. The need to monitor residents per their evaluated needs was discussed with Staff 1 (ED). He acknowledged the findings.
3. Resident 3 was admitted to the facility in 07/2021 and evaluated as a fall risk.Resident 3's service plan included interventions to reduce falls. Resident 3's facility Charting Notes and Incident Report and Investigations Worksheets for 07/2021 through 10/14/21 revealed three falls on 07/28/21, 08/03/21 and 08/12/21. The fall on 08/03/21 resulted in a hospital stay.There was no documented evidence the service planned fall interventions were monitored and reviewed to determine effectiveness. The need to monitor residents per their evaluated needs was discussed with Staff 1 (ED). He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct a significant change of condition assessment including findings, resident status, and interventions made as a result of severe weight loss for 1 of 3 sampled residents (# 1) who experienced a significant change of condition. Findings include, but are not limited to: Resident 1 was admitted to the facility in 02/2018 with diagnoses including dementia and was receiving hospice services.On all days of the survey, Resident 1 was assisted to eat meals and was provided a dietary supplement with his/her meal.On 07/07/21, Resident 1 was noted to weigh 125.2 pounds. On 08/27/21, Resident 1 weighed 111.6 pounds, a 13.6 pound or 10.8% body weight loss, in one month which constituted a severe weight loss.There was no documented RN assessment of Resident 1's severe weight loss.On 09/13/21, Resident 1 weighed 110.4 pounds. Staff 2 (RN Health Services Director) completed an RN assessment for the severe weight loss from 07/07/21 through 09/13/21 on 9/29/21.In the RN assessment on 09/29/21, Resident 1 experienced dental concerns regarding two loose front teeth which resolved. Resident 1 contracted COVID-19 which added to his/her decline. There was a hospice directive indicating staff should not be concerned if Resident 1 chose not to eat and anticipated further weight loss and decline.Resident 1 experienced a severe weight loss on 08/27/21 and continued to loose weight. The facility RN failed to complete a timely significant change of condition assessment that documented findings, resident status, and interventions made as a result of this assessment. The timeliness of the RN assessment was discussed with Staff 1 (ED), Staff 2 and Staff 16 (Corporate Operations) on 10/14/21. They acknowledged the finding.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#2) who had documented medication and/or treatment refusals. Findings include, but are not limited to:Resident 2's 10/01/21 through 10/14/21 MARs were reviewed. Resident 2 was noted to refuse all morning medications on 10/07/21 and 10/13/21.In an interview with Staff 9 (MT) on 10/15/21, she reported Resident 2 had refused all medications that morning as well. Staff 9 reported the physician had not been notified of any of the medication refusals. On 10/15/21, the need to ensure the facility notified prescriber of medication refusals was discussed with Staff 1 (ED) and Staff 3 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 8 and 15) had documented evidence of completion of First Aid certification and training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 10/14/21 and revealed Staff 8 (MT) and Staff 15 (CG), hired 09/07/21 and 08/10/21 respectively, lacked documented evidence they had completed First Aid certification and abdominal thrust training within 30 days of hire.The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (ED) and Staff 4 (Business Office Manager) on 10/14/21 and 10/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire and life safety training and failed to include required components on fire drill records. Findings include, but are not limited to:Fire and life safety records, reviewed between 05/2021 - 10/2021, revealed the following: * Fire drill records lacked the following components: - Escape route used; - Evacuation time-period needed; - Staff members on duty and participating; and - Number of occupants evacuated.* Fire and life safety training was not documented as completed every other month alternating with fire drills.On 10/14/21 the need to document all required fire drill information and provide fire and life safety training was reviewed with Staff 1 (ED). He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:On 10/14/21, observation during the survey revealed a gas fireplace was on and located in the living room where residents congregated. The glass face of the unit was cool to the touch but the upper metal aspect of the unit was hot to the touch. The surface temperature was measured and exceeded 140 degrees Fahrenheit. The need to ensure covers, grates or associating heating elements did not exceed 120 degrees Fahrenheit was discussed with Staff 1 (ED) and Staff 16 (Corporate Operations) on 10/14/21. They acknowledged the findings.On 10/15/21, Staff 16 disabled the fireplace to ensure it could not be turned on.

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 231, C 240, C 372, C 420 and C 540.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 14 and 15) signed job descriptions, completed all required pre-service orientation, and demonstrated competence in job duties within 30-days, and 2 of 2 long term staff (#s 10 and 17) completed 16 hours of annual training. Findings include, but are not limited to:A review of staff training records revealed:1. Staff 14 (CG) was hired 04/10/21. There was no documented evidence he had signed a written job description and demonstrated competency in his job duties within 30 days of hire in the following areas:* Providing assistance with ADLs;* Identification, documentation, and reporting of changes of condition; and* Conditions that require assessment, treatment, observation, and reporting.2. Staff 15 (CG) was hired 08/10/21. There was no documented evidence she had signed a written job description and demonstrated competency in her job duties within 30 days of hire in the following areas: * The role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition;* Conditions that require assessment, treatment, observation, and reporting; and* General food safety, serving and sanitation. 3. There was no documented evidence Staff 10 (MT) and Staff 17 (MT), hired 11/28/17 and 07/29/19 respectively, completed the required ten hours of training related to provision of care in community-based care and the required six hours related to dementia care annually during 2020.The facility's failure to ensure staff completed all required training was discussed with Staff 1 (ED) and Staff 4 (Business Office Manger) on 10/14/21 and 10/15/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C270, C 280 and C 305.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation areas was of sufficient weight and design to not aid in elopement. Findings include, but are not limited to:On 10/14/21 a tour of the facility courtyard showed the following:There were 22 hard plastic patio chairs which were easily moveable and not of sufficient weight or design to prevent potential elopement. The need to ensure the furniture in the outdoor recreation areas was sufficient in weight and design to not aid in elopement was discussed with Staff 1 (ED) and Staff 16 (Corporate Operations) on 10/14/21. They acknowledged the findings.