Desert Sage 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.

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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 In an interview on 08/20/24 at 1:30 pm, Staff 1 (RN) acknowledged that care plans were out of date and that they were working on updating the care plans with the Resident Care Coordinator.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; and Night 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; and Noc 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.

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.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action Resident 3 who was named in the citation will have all future resident to resident altercations where they are involved reported to the proper departments. The managerial staff including the Health services director  (HSD) and the Executive director (ED) will have training in the proper procedures for any and all self reporting to the appropriate state departments. The Executive director and HSD will create a proper system in house to track all self reports with the appropriate documents included. The self reporting will be reviewed and completed within 24 hours of incident. The HSD, Resident Care Coordinator (RCC) will be responsible for self reporting any occurance that requires and falls under the state provided regulations. The ED will review and keep track of the self report documents as stated above.

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.

The clinical team have created a binder system to monitor and manage incidents or occurrences in the community for resident #5 and resident #6. Upon discovery of any incident or occurrences for either of the residents, the instance will be properly documented and reported to the State of Oregon per the OAR's. The binder system that has been put in place will be updated daily or as indicated by the Resident Care Coordinator and Health Services Director. All incidents and occurrences will be reviewed daily during the daily clinical meetings. The Resident Care Coordinator, Health Services Director, and Executive Director will attend these meetings. The incident and occurrence investigation and reporting process will be evaluated on a weekly basis during the interdisciplinary meeting attended by the Resident Care Coordinator, Health Services Director, and Executive Director.    The clinical team will ensure that consistent guidelines are in place and utilized for accurate reporting and investigation of alleged abuse. The clinical team will consist of the Resident Care Coordinator and the Health Services Director. Executive Director oversight will also occur on a weekly basis, post interdisciplinary meetings.

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.

1. Resident #7 and #9's incidents were investiated by the Health Services Director (HSD).  Abuse and Neglect were ruled out so no reports to APS were made. This was completed during the day of survey. 2. The Executive Director, RCC, and/or HSD to follow-up with all incident reports within 24 hours to rule out abuse and neglect. If abuse and neglect are not able to be ruled out the ED is to report to APS immeidately after investigations is completed. 3. ED/RCC/HSD to utilize Incident Tracker daily during morning stand-up to ensure community is investigation incident reports and reporting timely. ED/HSD to review QMAR dashboard daily as well as 24 hour shift report to review all charting notes for prior day to make sure all incidents were reported if not following up with an incident report. These systems will be followed up daily. 4. The ED is responsible to make sure this task is completed.

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.

1. All incidents identified during survey for residents #6, #10, and #12 have been reported to APS.    2. Training will be done with the ED, RN and RCCs by regional staff to review the abuse and neglect reporting guidelines and the need for thorough and timely investigations and reporting to APS if abuse and neglect cannot be ruled out. Incident reports will be reviewed daily to ensure proper response and investigation. Additionally, the 24 hour report will be reviewed daily Tuesday - Friday to review all progress notes written that may indicate an event that requires investigation. On Mondays, the 72 hour report will be reviewed to include a review of all documentation from the weekend. Any incidents requiring report to APS will be reported timely. 3. This system will be evaluated 5 days a week as part of daily standup process. 4. The Executive Director, RN and RCC are responsible for maintaining this system.

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.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities The community has recently hired a new Lifestyles Director to ensure proper engagement of activities for residents named. The Lifestyles Director (LSD) will be appropriately trained in the activity program that is followed by the community. The ED will review the activity calendar and ensure that the activities listed are being completed on a weekly basis. The Lifestyles director will be responsible for creating, initiating and ensuring that the activities listed will be completed on a daily basis. The Executive Director will oversee all activity calendars and ensure the success of the Lifestyles Director.

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.

OAR 411-054-0036 (1-4) Service Plan: General The named residents #1, 2 and 3, will have their service care plans reviewed and adjusted to the the resident's current conditions. The clinical team (HSD, RCC, ED) will ensure that all appropriate Interim service plans (ISPs) are provided to staff. The clinical team will make available all new and current service care plans to all employees in a commonly known location. All service care plans will be reviewed on a quarterly basis and/or if a change of condition were to occur. The clinical team will host service care plan meetings with the resident's care team which is to include the resident, the resident's family/responsible party, caseworker (if applicable), and any outside care providers (if applicable). The clinical team will review and update service care plans on a quarterly basis. The HSD, and the RCC will ensure that service care plans are completed and show the needs of residents with oversight from the Executive Director.

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.

1. Resident #7's care plan updated to reflect behaviors an interventions, denture use, and meal assistance. Resident #8s care plan updated to reflect fall matt usage, side rails, alternating pressure air mattress, hospice services, behaviors and interventions, falls and interventions, mobility, ADL assistance, and Pain.  Resident #9's was printed out and placed in binders so staff can review at any time.  Residnet #9 care plan also updated to reflect fall matt, mobility, ADL assistance, hospice services provided, and fall interventions. 2. Training to be provided to RCC, HSD, and ED on service plan requirements and the service plan system (SPA) utilized by the community and with the understanding of service plans timelines as listed in the OAR 411-054-00036. 3. The communities service plan software is to be evaluated daily to see which resident's service plans are up for their quarterly review.  With any significant change of condition the RN to initiated assessment within 48 hours and to update care plan timely. 4. The ED/HSD/RCC are responsible for compliance.

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.

1. Service plans for resident's #6, #10, #11 and #12 were updated to be reflective of resident's current care needs and preferences, and to ensure they provide clear directions regarding the delivery of services. Updated service plans were printed and made available to staff. 2. All residents' service plans will be audited against their current care needs and preferences and updated to be reflective. Audit will also ensure that interventions provide clear directions to staff regarding the delivery of services. Updated service plans will be printed for staff to review and sign and then placed in the service plan binder to be readily available for staff. Training will be completed with care staff and medication techs on reporting service plan discrepancies and changes in residents' care needs to the Health Services Team. Executive director, RN and RCC will complete NurseLearn course 'Creating Individualized Care/ Service Plans'. 3. Service plans will be evaluated and reviewed upon move-in, within 30 days of move-in, quarterly and with change of condition. 4. The Executive Director, RN and RCC are responsible for maintaining this system.

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.

OAR 411-054-0036 (5) Service Plan: Service Planning Team The clinical team will re-visit the current service care plans for residents #1, 2 and 3, and upon new service care plan reviews will adjust accordingly and invite the residents care plan team to the service care plan meeting. Service care plans will be reviewed on a quarterly basis and/or as needed based on a change of condition. Service care plan meetings will occur on a quarterly basis with all needed parties invited. Those included n service care plan meetings will be the communities HSD, RCC, resident, resident's responsible party/family, caseworker, and/or anyone else that is part of the resident's care team. The HSD and the RCC will be responsible for inviting all appropriate parties to quarterly service care plan meetings with ED providing oversight and being the final signature on the service care plans.

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.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring Change of condition statuses for resident #2 will be reviewed and evaluated by the clinical team which will include the HSD and the RCC. Both parties will notify the resident's care team via fax, email, and/or telephone call. All appropriate documentation will be completed. Staff will have change of condition information provided to them and kept in commonly known areas. Change of conditions will be completed within 24 hours of discovery. High Risk meetings with the HSD, RCC and the ED will be held and the determination of change of condition need will be discussed at that time. Change of condition needs will be evaluated on a weekly basis via the high risk meeting. The Health services director, RCC will be responsible for initiating any change of condition with ED oversight.

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.

Review of documentation by care staff or 3rd party providers for Resident #5 and Resident #6 will be reviewed by HSD (Health Services Director) daily, or as indicated, for complete information related to wound progression, treatment, and plan of care. At time of reported resolution of wound, Health Services Director will perform additional/final assessment of wound to confirm findings and conclude monitoring for incident or occurrence. Collaborative review of active Change of Condition (COC) service plans is to be done bi-monthly during clinical meeting by Executive Director, Health Services Director, and Resident Care Coordinator. Team to review documentation r/t resident functionality and condition, assess for need for changes to COC to serve current needs of resident, and determine what changes are to be made to better care for resident. In addition to bi-weekly review of documentation related to changing resident needs, resident responses to interventions specific to resident will be reviewed for efficacy and/or need for change, dependent upon success of intervention when utilized by staff.

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.

1. Resident #7's alert charting note from 8-31-24 has been resolved as well as 09-06-24 for starting new medication. Resident #8 and #9 incidents will be recorded and reported per state regulations. 2. Community has HSD/RCC/Med-Techs who are now trained on systems and policies and procedures for short term change of condition.  Any resident who has an incident will be monitored by HSD at leat weekly. 3. All incidents will be evaluated by clinical team and ED on a weekly basis. 4. The RCC, HSD will ensure all incidents are reviewed and documented as they occur with ED oversight on a weekly basis.

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.

1. Residents #6, #10, #11 and #12 were assessed for the change of conditions identified during survey. Service plans were reviewed and updated to reflect clear instructions for monitoring and interventions related to current care needs. 2. To prevent recurrence, Health Services Staff will be reeducated on the alert charting guidelines and when to notify the RN. When a change of condition is identified, the resident will be placed on alert charting and a resident specific ISP will be implemented with interventions and monitoring instructions related to the reason for being put on alert. Medication Techs will document on the resident's condition until the alert charting is resolved by RN or designee. When a change of condition is determined to be a significant change, a comprehensive nursing assessment will be triggered for the RN to complete, and the condition will be monitored until resident is stable or establishes a new baseline. The 24-hour summary will be reviewed Tuesday - Friday as part of daily standup meeting to identify any documentation that might indicate a change of condition that was not put on alert. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. Additionally, the ED, RN and RCC will complete the Oregon Care Partners course 'Compliance Series: Understanding Changes of Condition for Community-Based Care (CBC) Facilities in Oregon. 3. This system will be evaluated five days a week as part of daily standup meeting. This system will further be evaluated monthly as part of the facility Continuous Quality Improvement (CQI) process which includes a review of all residents who require significant change of condition monitoring. 4. The Executive Director, RN and RCC are responsible for maintaining this system.

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.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services The Health Services director has created a tracking method for all wounds for the residents #2 and 3 and has trained in proper wound tracking with the regional nurse. The Health services director will do weekly high risk meetings with resident overview to determine if a change of condition is required. The Health services director will keep a weekly record of any wounds noted and a high risk meeting with the clinical team which is to include the HSD, RCC and the ED. HSD will continue to document changes on resident #2 and 3 until resolved. The wound tracker will be updated weekly. Along with any outside care provider notes that the HSD will need to review. The Health services director will be responsible for maintaining the weekly wound tracker with the oversight provided by the ED during the HIgh risk meeting.

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.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse All residents mentioned (resident #1)  that have refused any medications and/or services will have faxed docementation sent to the primary care physician on a daily basis by med tech staff. All med techs will be trained on the processes and the forms around the medication/ service refusal. All med techs will be trained to document the refusals in the appropriate locations and the appropriate manner. The Resident care coordinator will pull a weekly report and review all refusals to ensure that the proper steps have been done and that the residents primary care physician has been notified. Medication and/or service refusals will be reviewed on a weekly basis via the report system that the RCC will navigate. The resident care coordinator will be responsible for reviewing and training of med techs with HSD and ED oversight.

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.

1. Physician for resident #10 was notified of all refusals identified during the survey. Ancillary orders in PCC have been identified to indicate physician preference on medication and treatment refusals. 2. Training will be conducted with medication techs and health services team related to regulations for notifying providers of resident refusals of medications and treatments timely, unless there is a signed order specifying not to notify of refusals. A list of all residents that require provider notification for refusals has been created and posted in the medication rooms. The 24-hour/72-hour report will be reviewed during Daily Clinical Stand-up Monday-Friday to identify any resident refusals and verify notifications have been made. 3. This will be evaluated weekly with MAR audits to verify appropriate notifications are occurring. 4. The Executive Director and RCC are responsible for maintaining this system.

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.

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff All staff mentioned will have all necessary trainings and competency skills done within the first 30 days of being hired. A new Business office manager has been hired and will create a tracking system of trainings and new hire requirements as determined by the State. The Business office manager will get the appropriate training to ensure that all newly hired staff members have the state required trainings within the first 30 days of the staff member being hired. The BOM will work together with the resident care coordinator to ensure that all staff have all needed trainings completed prior to any hands on training. The BOM will audit employee files on a weekly basis via random selection to ensure that all staff have pre-service trainings and the yearly needed continued education hours. The BOM will be responsible for the continued maintenance of the eomployee files with ED oversight.

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.

Mandatory First Aid and abdominal thrust training will be scheduled within the community for new employees and employees with expiring certifications monthly. If training cannot be completed within the community, alternative classes/training will be scheduled at external sites as needed to remain in compliance with state requirements. Proof of certification will then be added to the employee file. Review of new employee files will be conducted by the Business Office Manager during the first 30 days of employment to ensure that training and certifications remain on course for completion within the required time limit. BOM (Business Office Managers) will communicate with new employees to ensure their compliance with state policy. New employee file review will be conducted weekly by BOM in the first 30 days of employment for required documentation. The Business Office Manager maintains, reviews and updates all employee files to ensure they comply with state regulations. The Executive Director alongside the Business Office Manager will review new employee files bi-monthly for accuracy and ensure all files are complete.

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.

1. HSD to conduct inservice on abdominal thrust training for staff #31,34,35 (and all staff) during next all staff inservice training.  Staff #31, 34, and 35 to take the first course through Relias. 2. A new-hire checklist will be implemented that includes pre-service training and orientation and additional trainings that are required to be completed in the initial 30 days of employement. A job specific comptency checklist will be maintained by the RCC until completed. The job specific skills checklist will identify competencies that must be completed preservice and those that must be completed within 30 days of hire. The job specific skills checklist will include dates of observation and skills check and will be signed by the trainer and trainee. The community is not to schedule this employee until the pre-service skills checklist is completed. The community will not schedule the new employee beyond 30 days unless the required items on the job specific skills checklist have been completed.  The checklist will be given to the business office manager to be filed in the employees file. 3. The areas of correction will be evaluated weekly x 4 and than monthly thereafter. 4. This is the responsbility of the ED/RCC/HSD and BOM to ensure these corrections are monitored and completed.

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.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety All staff inservice meetings will include at minimum one Fire, life and safety topic moving forward. At the staff inservice meetings, staff will be presented with an itinerary on the topics discussed and staff will asknowledge the itinerary with signature. All staff inservice meetings will be held at the minimum of a monthly basis. The Environmental service director will be responsible for creating a timeline with topics for the all staff inservice meetings with ED oversight and acknowledgement via signature on the itinerary.

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.

OAR 411-057-0140(2) Administration Compliance 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.

Please refer to C231 and C372 POC Response

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.

Refer to C-231, C-361, C-362, 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.

Refer to POCs for C231 and C295

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.

OAR 411-057-0155(1-6) Staff Training Requirements All staff mentioned will have all necessary trainings and competency skills done within the first 30 days of being hired. A new Business office manager has been hired and will create a tracking system of trainings and new hire requirements as determined by the State. The Business office manager will get the appropriate training to ensure that all newly hired staff members have the state required trainings within the first 30 days of the staff member being hired. The BOM will work together with the resident care coordinator to ensure that all staff have all needed trainings completed prior to any hands on training. The BOM will audit employee files on a weekly basis via random selection to ensure that all staff have pre-service trainings and the yearly needed continued education hours. The BOM will be responsible for the continued maintenance of the eomployee files with ED oversight.

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.

Please refer to C372, C231, C270, C372, Z142, Z155 and Z164 POC

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.

1. Staff #s 31, 34, 35, and 36 are to complete via Relias or Oregon Care Partners training on: Resident Rights, 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 communication and responding to distressful behavioral symptoms, strategies for addressing social needs and engaging persons with dementia in meaningful activities, 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 interventions, lighting, room temperature, noise, etc); Family support and role of the family may have in the care of the resient, how to regonize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* How to provide personal care to aresident with dementia, including an orientation to the resident's service plan; and * Use of supportive devices with restraining qualities in memory care communities.  Staff 31 and 34 are to compete the following: * 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. The are to compete this using Relias and or Oregon Care Partners. Staff #35 is to complete the following: changes associated with normal aging, and general food safety, serviing and sanitation using Relias and/or Oregon Care Partners.   2. A new-hire checklist will be implemented that includes pre-service training and orientation and additional trainings that are required to be completed in the initial 30 days of employement. A job specific comptency checklist will be maintained by the RCC until completed. The job specific skills checklist will identify competencies that must be completed preservice and those that must be completed within 30 days of hire. The job specific skills checklist will include dates of observation and skills check and will be signed by the trainer and trainee. The community is not to schedule this employee until the pre-service skills checklist is completed. The community will not schedule the new employee beyond 30 days unless the required items on the job specific skills checklist have been completed.  The checklist will be given to the business office manager to be filed in the employees file. 3. The areas of correction will be evaluated weekly x 4 and than monthly thereafter. 4. This is the responsbility of the ED/RCC/HSD and BOM to ensure these corrections are monitored and completed.

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.

1. Staff #38, #40, #43 and #44 have completed the missing pre-service dementia training topics and competencies have been updated to include all required job duties. A complete audit of training records has been completed to identify any missing components and these will be completed by 4/25/25. 2. To prevent recurrance, new training plans have been implemented that meet all required components and have been approved by the state. New hires will not be allowed to start training until all pre-service training requirements are completed. Additionally, all training and demonstration of competency in job duties will be completed within 30 days of hire. A training grid has been implemented to track completion of required trainings. 3. This system will be evaluated monthly as part of the CQI process, which includes a review of the training grid to ensure compliance with all training requirements. The Executive Director is responsible for maintaining this system.

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.

OAR 411-057-0160(2b) Compliance with Rules Health Care 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.

Please refer to C270 POC response

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.

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.

Refer to POCs for C260, C270, C303, C305, C310, C330 and C362

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.

1. Staff #38 and #41 were counseled regarding the observed lack of following infection control practices related to hand hygiene. Proper hand hygiene and infection control basics will be reviewed with all staff at the next staff meeting to ensure all staff are aware of infection control practices. An additional hand sanitizer dispenser has been installed in the dining room area, and staff are also provided pocket size hand sanitizers to use when not in close proximity to a dispenser. 2. To prevent recurrance, all newly hired staff will complete an approved infection prevention training as part of their pre-service training requirements. Additionally, staff will receive infection prevention training at least annually. Infection Prevention Specialist and other management staff will conduct periodic observations of staff to confirm that correct procedures are being followed. 3. This will be evaluated weekly by observations of staff by the Infection Prevention Specialist or other management staff. 4. The Executive Director, RN and RCC are responsible for maintaining this system.

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.

1. All Medication Techs have been trained on the importance of administering medications as ordered by their provider, along with the expectation to re-attempt if resident is sleeping or discuss with RN if medication times do not appear to work for a certain resident. Training also included how to properly document if a medication is not given for any reason. Physician Orders for resident #12 have been reconciled to ensure they match what is on the MAR. 2. All residents most recent signed physician orders will be reconciled to match the orders on the MAR. Training will be completed with medication techs and health services team on policy, procedures and regulations related to medication administration. 'Triple Check Process' for verifying new prescription orders has been implemented to ensure nurse review of all orders to verify accuracy of order entry into eMAR.  The 24-hour/72-hour report will be reviewed during Daily Clinical Stand-up Monday-Friday to identify any eMAR administration notes that indicate medications were not administered and the reason why. Follow up education will be provided when needed based on documentation. 3. This system will be evaluated weekly with MAR audits, as well as quarterly with reconciliation of physician orders. 4. The Executive Director, RN and RCC are responsible for maintaining this system.

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.

1. MARs for residents #10 and #11 were updated to include clear parameters for prn use. A complete MAR audit for all residents was done by regional team and reviewed with ED, RN and RCC to provide training and ensure all PRN orders have clear parameters as to when to give, including clear instructions when there are 2 or more PRNs with the same reason for use. 2. A complete MAR audit will be conducted by regional team on all residents to verify all orders have required components, including clear resident-specific PRN parameters and medication-specific instructions. Training will be completed with medication techs and health services team on policy, procedures and regulations related to medication administration. 'Triple Check Process' for verifying new prescription orders has been implemented to ensure nurse review of all orders to identify orders that need resident-specific PRN parameters and/or medication-specific instructions. The 24-hour/72-hour report will be reviewed during Daily Clinical Stand-up Monday-Friday to identify discrepancies with documentation in the eMAR. 3. MAR audits will be conducted weekly by Resident Care Coordinators to identify discrepancies in documentation. PRN audits will be completed monthly for continued verification of clear resident-specific instructions. 4. The Executive Director, RN and RCC are responsible for maintaining this system.

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.

1. Resident #11's MAR was updated to include all required components, including non-drug interventions that must be attempted prior to administering the medication. All Health Services staff were trained on the regulation regarding psychotropic medications and how to document appropriately. A complete MAR audit will be done by the regional team to ensure all PRN psychotropic medications have clear instructions for administration, including how the resident indicates a need for the medication. Audit will also ensure resident specific non-drug interventions are in place to attempt prior to the use of the medication unless an order from the provider negates the need for non-drug interventions. 2. To prevent recurrence, all provider orders will be reviewed through facility triple check process, which includes review by RN to ensure all necessary components are in place. EMAR administration progress notes will be audited as part of the 24 hour daily audit (72 hour audit on Mondays) to ensure appropriate documentation. Ongoing education will be provided to medication aides as needed based on findings of audits. Physician orders will also be reviewed quarterly by RN and sent to provider for signature to provide coordination of care. 3. This system will be evaluated monthly as part of the facility CQI program which will include an audit of all PRN psychotropic medications. 4. The Executive Director, RN and RCC are responsible for maintaining this system

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.

1. The Service Planning Team (Executive Director, RCC, and HSD) are to address the care plans, including significant changes of condition to ensure accuracy of ADLs to reflect care needs.  With accurate care plans the community can utilize its propritary ABST tool to generate staffing needs for the community. 2. Training to be provided to Executive Director, HSD, and RCC on how to properly use the communities service plan system so care plans can be updated corrections to ensure they are reflective of resident needs. 3. This will be ongoing as quarterly care plans become due, and/or changes of condition arise. As updates are completed the Executive Director is immediately review how these updates impact their ABST score to determine staffing needs. 4. The executive director is responsible for this.

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.

1. ABST has been updated to accurately reflect time needed to meet all current resident needs, including sampled and unsampled residents. 2. The ABST will be updated and reviewed for accuracy prior to move in, within 30 days, quarterly or with any change of condition. 24/72 hour report will be reviewed to ensure all changes in condition have been identified and updates will be made to the ABST when needed. 3. This system will be evaluated weekly to ensure that all necessary updates to the ABST have been completed and that the times are accurate and reflective. This will also include verification that the staffing plan still meets the scheduled and unscheduled needs of the current population. 4. The Executive Director and RCC are responsible for maintaining this system.

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.

Please refer to POC Responses addressed above to C372, C231, C270, C372, Z142, Z155 and Z164 POC Executive Director will be responsible to ensure that compliance in OAR's is being demonstrated in said community with regional team oversight.

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.

1. For corrections refer to: C-231, C-260, C-361, C-372, C-555, Z-142, Z-155, Z-162, Z-176

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.

Refer to POCs for C231, C260, C270 and Z155

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.

1. The Environmental Service Director (ESD) has fixed the audible alarms exiting to the center courtyard from the TV room and the door exiting to the north courtyard from the events room. They are in working order now. 2. The ESD has entered a weekly work order into TELS (work order management system) which will alert him to check the alarms every Wednesday. 3. Every Wednesday 4. The ESD will be responsible for the weekly checks.

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.

1. Room 204 was rekeyed.  All resident rooms were unlocked and training given to staff regargding locking of rooms.  Residnet have been giving keys were are taped in their closets.  Rooms 101, 105, 110, 202, and 302 will have individually specific markers (e.g. photos of resident, names of resident, etc) so residents can identify their rooms. 2. Staff provided education on not locking residnet rooms. 3. ED/ESD will randomly check resident apartments during routine walk throughts daily. All other department heads will be instructed to check closed doors to ensure they are not locked as they move around the community daily.  Any noted locked door should be immediately unlocked unless the resident residing in that apartment manages their own key and lock.  Immediate verbal correction to staff will happen to ensure they do not lock doors. 4. ED/ESD will document finds of door checks at least weekly for 4 weeks and than at least quarterly.

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

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

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

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

The findings of the 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 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.

Kitchen will receive weekly cleaning by kitchen staff, weekly cleaning will be logged and maintained, including but not limited to the following areas; sides, front,and interior of range; interior of drawers throughout the kitchen; the can opener blade and casing; rack shelving throughout the kitchen; rack shelving in the walk in refrigerator; appliances including standing mixers, blenders, and food processor; Surfaces of food bins in dry storage; dishwashing area equipment and flooring; floor throughout kitchen. This log will be maintained and overseen by executive chef or designee. Automatic cleaning solution will be logged and monitored for temperature and parts per million daily on temperature log sheet near dishwasher, overseen by executive chef or designee Food items in walk in refrigerator will be dated and labeled, Kitchen staff will check daily, overseen by executive chef or designee

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

Boxes of food will be stored on shelving and not the floor of the walk in freezer. Kitchen staff will check daily, overseen by Executive Chef or designee Packaged food items will be dated when opened. Kitchen staff will check daily, overseen by Executive Chef or designee Any cans dented prior to or after receipt will be sent back or disposed of. This will be checked weekly by kitchen staff, overseen by executive chef or designee no cups or spoons will be left in food bins. This will be checked daily, overseen by Executive Chef or designee back door of kitchen will be secured with mesh netting when left open to prevent entry of pests, this will be checked anytime the door to the kitchen is propped open, overseen by executive chef or designee caregiving staff will don aprons when serving food to residents. This will be checked by kitchen staff and overseen by Executive chef or designee at all meal times

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, 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.

Kitchen staff have cleaned splatters, spills, drips, and debris throughout kitchen including but not limited to: Hand washing sink and wall Shelving throughout kitchen, baking pans, Exterior and interior of drawers carts, fryer, sides and behind range, and stand mixer Kitchen currently in compliance for above items. Bins of food, Can opener, and radio in prep area will be clean of splatters, spills, drips and debris by September 17th, 2022. Community also scheduled with All American LLC to have hoods cleaned on August 18th, 2022. Hoods will be within compliance for cleanliness August 19th, 2022. Kitchen will follow a daily weekly and monthly cleaning schedule and checklist which will be posted in the kitchen area, overseen by Executive Chef or designee. Kitchen will be in compliance by September 17th, 2022 Boxes on freezer floor to be rearranged onto walk in Freezer shelves by September 17th, 2022. Boxes will no longer be kept on floor of walk in freezer and audited by Executive chef or designee in line with kitchen cleaning schedule. Cups and scoops have been removed from food bins, will be hung within food bins above and not in food within food bins by September 17th 2022. This will be overseen by Executive chef or designee in line with cleaning schedule Undated, unlabeled and uncovered foods have been disposed of, all food within walk in refrigerator is currently and will be dated, labled, and covered. Kitchen is currently in compliance. This will be overseen by Executive chef or designee in line with kitchen cleaning schedule.

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.

Please see corrections as listed for tag C240 above.

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 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.

Incidents involving sampled residents 3 and 4 reported to APS on 10/15/21. Community leadership has reviewed Oregon Abuse reporting requirements and duties as mandatory reporters. Additionally, an inservice on the Oregon Abuse Guidelines will be conducted by 12/14/21 with all community staff. Any incident with the potential for abuse or neglect will be reported according to the Oregon Abuse Reporting guidelines. ED will review all incidents with RVP and/or Ops specialist to ensure compliance with reporting and investigation requirements on an ongoing basis. ED or designee will continue to review incident reports and community practices to ensure compliance with reporting and investigation requirements on an ongoing basis.

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.

Deep cleaning schedule has been posted and will be reviewed by ED, ESD or designee weekly. ED has reached out to Bend Cleaning Company, awaiting scheduled quote for cleaning of observed areas of concern listed under C240. Inservice on OAR-333-150-000 to be held with all kitchen staff before 12/14/21 highlighting kitchen cleanliness and food sanitation practices.

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.

Resident 3's falls have been reviewed and documented, was noted to be at risk of falls and continues to fall. the documentation will continue to reflect changes in interventions as appropriate. Residents will be followed in high risk resident meeting and a change of condition conducted if and when warranted. Incidents of falls will be reviewed by ED and HSD for the need of a RN change of condition assessment, a weekly interdisciplinary resident meeting is conducted to review high risk residents and current interventions in place to address residents' specific needs. The ED will monitor for ongoing compliance Upon investigation by ED,HSD,or designee, service planned fall interventions to be monitored and reviewed for their effectiveness. ED to review and monitor service planned fall interventions to determine effectiveness in a timely manner by 12/14/21.

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.

Inservice to be provided by 12/14/21 regarding weight collections, data entry, and reporting. Approximately weekly, HSD and designee(s) will review all residents' weights for RN assessment and timely intervention of significant change of condition. Residents will be followed in high risk resident meeting and a change of condition conducted if and when warranted. Significant change of condition will be reviewed by ED and HSD for the need of a RN change of condition assessment, a weekly interdisciplinary resident meeting is conducted to review high risk residents and current interventions in place to address residents' specific needs. The ED will monitor for ongoing compliance

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.

Staff education will be completed regarding residents rights to refusal and notification to physician as requested by the prescriber by 12/14/21 An audit will be performed frequently throughout the week by RCC or designee to ensure prescriber notification as requested by the prescriber .

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.

ED, BOM, or designee to complete audit and collect evidence of documentation of all required training in specified time frames. ED, BOM or designee to ensure all new hires are certified for first aid and trained in abdominal thrust within 30 days of hire. ED reaching out to various First aid/cpr certifiers in interest of scheduling recurring first aid/cpr courses.

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.

Fire drills will be conducted following the Oregon fire drill code. ESD to fill fire drill log completely, listing: escape route used, evactuation time period needed, staff members on duty and participating, and number of occupants evacuated. Fire and life safety training to be conducted on alternating months from firedrills.

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.

Community has secured metal grates over top of upper metal aspect of fireplaces to prevent direct touch of upper metal aspect.

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.

See plan of correction for C231, C240, C372, C420, and C540

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.

ED, BOM or designee to ensure all staff complete 10 required training hours related to provision of care in community based care and required 6 hours training related to dementia care annually and within 30 days of hire by 12/14/21. ED,BOM, or designee to audit employee files to verify that all employees have signed job desciption, and filled skills checklist by trainee and trainer within 30 days of hire by 12/14/21.

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.

See plan of correction for C270, C280, and C305

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.

The lightweight patio furniture was removed from use during the survey, furniture is currently being evaluated for the need to replace or if can be secured and have continued use at the community. ED, ESD. or designee to ensure the community has adequate appropriately weighted and or secured outdoor furniture to provide a safe and secure outdoor environment. ED, ESD, or designee to monitor for ongoing compliance.

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

The findings of the 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.