Avamere at Hillsboro

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OARS 333-150-000. Findings include, but are not limited to:

The kitchen and MCC kitchenette were toured at 11:17 am on 07/01/25. The following was identified:

a. The following areas were in need of cleaning:

* A build-up of dust was observed on the galvanized metal shelving, the exterior of the ice maker, and the ceiling;
* A build-up of grease drips was observed on the sides of the fryer;
* The dry storage bins containing sugar, flour, and oats had a build-up of grime on the exterior;
* The main kitchen doors and frames had chipped paint and black scuff marks; and
* The MCC kitchenette refrigerator interior, floors, walls, and cupboard exteriors had a build-up of food spills and debris.

b. The following items were in need of repair:

* Baseboard was missing along the bottom of the wall in front of the hot food pass and on the bottom corner next to the oven;
* The plastic cold food prep board was worn with deep grooves and plastic chipped off;
* A rubber spatula was worn with pieces chipped off; and
* The laminate wall below the hot food station had worn/chipped pieces and metal peeling back rendering it uncleanable.

c. Staff beverages were observed on the shelf of the hot food service station directly above an uncovered cake intended to be served to residents. Surveyor requested the beverages be removed.

d. Staff did not have alcohol wipes available to use for food temping thermometers.

e. Staff were observed delivering meals to MCC resident rooms without covering beverages or soup.

The above areas were toured with and/or reviewed with Staff 1 (ALF ED) at 12:45 pm on 07/01/25. She acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

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

This Rule is not met as evidenced by:

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

Refer to C 240.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to complete fire drills on alternate months and document all required components of fire drills. Findings include, but are not limited to:



Fire drill records from 04/2024 through 09/2024 were reviewed on 09/12/24. The facility failed to document the following required components:



* Date & time of fire drill;

* Location of simulated fire origin;

* Escape route used;

* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time-period needed;

* Staff members on duty & participating; and

* Number of residents evacuated.



There was no documented evidence fire drills were provided to staff on alternate months of fire and life safety training.



On 09/12/24, the need to ensure all required components of fire drills were documented and fire and life safety instruction to staff was provided on alternate months was discussed with Staff 3 (ED) and Staff 5 (Director of Maintenance). They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

(1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the grounds were orderly and free of litter and refuse, and provided storage for maintenance equipment, including yard maintenance tools. Findings include, but are not limited to:



The interior courtyard was toured on 09/09/24. The following was identified:



* A large, opened bag of potting soil on the patio contained multiple pieces of litter.



* A crumpled latex glove was observed in the bark mulch.



* An upside-down stack of tomato cages, with metal ends sticking upright, was observed in the bark mulch.



These findings were reviewed in a tour of the facility on 09/10/24 with Staff 1 (Administrator 1) and Staff 5 (Director of Maintenance). They acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior

(3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to:



During observations conducted 09/09/24 the following were found to need cleaning and/or repair:



* Multiple door frames and doors throughout the facility had chips, gouges and/or scrapes; and

* The window blinds in resident room 112B had multiple broken and crumpled slats.



These findings were reviewed in a tour of the facility on 09/10/24 with Staff 1 (Administrator 1) and Staff 5 (Director of Maintenance). They acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors

(d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

This Rule is not met as evidenced by:

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 C420, C510, and C513.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Cut and paste here....

OAR 411-057-0155(1-6) Staff Training Requirements

(1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 06/20/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities.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.
The findings of the re-visit to the kitchen inspection of 06/20/24, conducted 08/20/24, are documented in this report. The facility was found to be in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 06/20/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: * Flooring throughout kitchen - spills/food debris/dust/dirt - dishwashing area, under counters, next to ice cream freezer, between stove/oven & steam table, dry storage, walk in refrigerator;* Vents and surrounding ceiling - significant dust build up - above steam table, outside dry storage area, near ice maker;* Walls - dishwashing area - black matter around caulking, brown drips below shelf on dirty side, next to soup warmer, behind/above two door refrigerator; * Shelving above and below counters throughout the kitchen - food debris/dust/drips/spills - dishwashing area, prep counter with two drawers next to commercial mixer, prep counter near entrance to dining room;* Cart containing large container of grease with significant spills;* Interior of microwave - food splatter; and* Food bin lids and exterior - dry food debris. Improper food storage: * Refrigerated items open to air, not securely closed;* Refrigerated items not labeled/dated; * Uncovered salads on counter;* Onions and potatoes on floor in dry storage:* Open box of rice in dry storage; * Open undated bags of almonds and peanuts in dry storage; and* Food stored below sink next to sanitation bucket and unlabeled spray bottle. Other areas of concern: * Lack of thermometers in walk in refrigerator and small refrigerator on service line;* Dishwashing machine not meeting minimum temperature - maintenance checked and called vendor to check immediately. Facility to use three-compartment sink until dishmachine was reaching the required temperature;* Two uncovered garbage cans near dining entrance;* Very worn colored cutting boards - cuts/grooves - uncleanable;* Uncovered ceiling light; * Build up of ice preventing freezer door from closing completely; * Not using pasteurized eggs, PIC stated eggs were served over easy and sunny side up occasionally - encouraged to use eggs fully cook if cannot be returned for pasteurized eggs; and * Kitchen staff changing gloves on service line without washing hands between dirty and clean.The areas of concern were discussed and observed by Staff 1 (PIC/Cook) and discussed with Staff 2 (Business Office Manager) and Staff 3 (Corporate Staff) on 06/20/24. The findings were acknowledged.

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

The findings of the kitchen inspection, conducted 05/09/23, 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.
The findings of the first revisit for the kitchen inspection on 05/09/23, conducted 06/20/23, 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.
The findings of the second re-visit of the annual kitchen inspection on 05/09/23, conducted 08/23/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

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 main kitchen, memory care kitchenette, food storage areas, food preparation, and food service on 05/09/23 revealed the following:* Open packages of dry cereal stored on a shelf above clean dishes in the main kitchen food service area;* Garbage barrels used for food disposal did not have covers available when not in use;* Build up of food material on the grill surface and overflow drawer of the grill top;* Sanitizer buckets with cleaning cloths were tested using test strips and were shown to have a lower concentration of sanitizing chemical than the acceptable range on the test strip instructions;* The sanitizing solution distributed by the "Ecolab" dispenser installed above the three compartment sink was tested by kitchen staff, using the test strips, and showed the chemical sanitizer was below the acceptable range; * Cooked fish being stored in a warm oven, prior to serving, measured 120 degrees with a probe thermometer (below the required temperature of 135 degrees Fahrenheit);* One kitchen staff was observed without properly restrained hair while washing dishes and performing food preparation; * The refrigerator and freezer in the memory care kitchenette had dried spills and food particles on the shelves throughout; and* Direct care staff in the memory care unit, who were designated to also serve meals, did not have aprons to wear during food service tasks. The following areas/items were in need of repair: * Exposed wood surfaces, scuffs and blackened areas on the doors exiting the kitchen into the dining room;* Exposed wood surfaces and damage to the cabinets below the coffee and juice service areas in the dining room; and * The hot water sitting in hand washing sinks in the main kitchen needed an extended period of time, in excess of three minutes, for the water to get hot (temperature obtained was a maximum of 112 degrees Fahrenheit). During an interview on 05/09/23, Staff 2 (Human Resources Manager) provided copies of food handler certification cards for kitchen staff. A review of the records showed ten kitchen staff did not have a current food handler's card. Staff 2 acknowledged the findings. At 11:15 am, the above areas were discussed with Staff 1 (Kitchen Manager) and Staff 3 (Administrator). They acknowledged the findings.
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. This is a repeat citation. Findings include, but are not limited to:a. Observations of the main kitchen, memory care kitchenette, food storage areas, and food preparation on 06/20/23 revealed the following:* Garbage barrels used for food disposal (in the main kitchen and the memory care kitchenette) did not have covers available when not in use;* Staff food was stored in the refrigerator used for resident food in the memory care kitchenette;* Food items found in the refrigerator and freezer in the memory care kitchenette were not properly covered, labeled and/or dated;* The interior and exterior oven and countertops in the memory care kitchenette had dried spills and food particles; and* Direct care staff in the memory care unit, who were designated to also serve meals, did not have aprons to wear during food service tasks. The following item was in need of repair: * Two ceiling tiles above the three compartment sink were damaged. b. During an interview on 06/20/23, Staff 2 (Human Resources Manager) provided copies of food handler certification cards for kitchen staff. A review of the records showed Staff 5 (Dietary Server) did not have a current food handler's card. Staff 2 acknowledged the findings. At 11:40 am, the above areas were discussed with Staff 4 (Executive Director) and Staff 3 (Administrator in Training). They acknowledged the findings.

Based on interview, observation and review of documentation, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240.

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

Based on interview and record review it was confirmed that the facility failed to notify a resident's emergency contact in an emergency. Findings include: During an interview on 11/15/2022, Staff #1 (S1) stated that there was a time when the facility forgot to notify the resident ' s emergency contact when the resident went to the hospital.A review of Resident #1 (R1) service plan dated 8/19/2022 and progress notes dated 9/2/2022-11/152022. The progress notes show that on 10/24/2022 that the emergency contact was not notified about their family member going to the hospital on 10/23/2022.On 11/15/2022, these findings were reviewed and acknowledged by S1.Plan of Correction: S1 had a re-education last week for informing family members or Power of Attorney (POA's) of residents when the resident is sent to the hospital.

Based on interview and record review it was confirmed that the facility failed to ensure only individuals with a diagnosis of dementia who are in need of support for the progressive symptoms of dementia for physical safety, or physical or cognitive function may reside in a memory care community. Findings include: During an interview on 11/15/2022 Staff #1 (S1) stated that Resident #1 (R1) had a diagnosis for dementia when living in the assisted living but admits that when R1 moved to memory care the facility could not find a formal diagnosis. A review of R1 service plan dated 8/19/2022 and progress notes dated 9/2/2022-11/15/2022 state no medical diagnosis found.On 11/15/2022, these findings were reviewed and acknowledged by S1.Plan of Correction: The RN has reached out to the resident 's doctor to see if she has a formal diagnosis. awaiting doctors' response.

The findings of the re-licensure survey conducted 3/31/21 through 4/5/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the relicensure survey of 4/5/21, conducted 06/15/21 through 06/16/21, 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 C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the second revisit for the re-licensure survey of 4/5/21, conducted 8/19/21 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to report incidents of suspected abuse to the local APD office and failed to promptly investigate incidents for 1 of 1 sampled resident (#1) who had documented incidents. Findings include, but are not limited to:Resident 1 had a diagnosis of dementia and was noted, according to progress notes, the following:*On 1/23/21 was verbally abusive to "others" and to roommate " ...threatening to kill [roommate name] ..." and on 1/24/21 was observed yelling " ...how [s/he] wanted to kill everyone ..." and " ...roommate needs to locked up and behind bars ..." Staff documented that the roommate was "afraid" to go back into room;*On 3/15/21 the resident was screaming at a male resident, " ...calling him names ... " and " ...threatening to kill him ..." A later progress note, 3/17/21, identified the male resident as having " ...anxiety because of [Name of Resident 1] ..." and*On 3/29/21 the resident was found naked with a male resident who was also naked. Male resident was observed to have hand in " ...residents genital area ..."Two of the three incidents (1/23/21 and 3/29/21) were not reported immediately to the local unit and not promptly investigated. The incident on 3/15/21 was not reported until four days later, on 3/19/21, when the investigation was completed.The failure to immediately report incidents of suspected abuse and promptly investigate was reviewed with Staff 1 (ALF Executive Director), Staff 2 (MCC Administrator) who acknowledged the findings. On 4/2/21, the facility provided documentation that the incidents of 1/23/21 and 3/29/21 had been reported to the local unit.

Based on observation, interview and record review, it was determined the facility failed to consistently provide assistance with ADL's for 2 of 2 sampled resident (#s 1 and 4) who required assistance with bathing. Findings include, but are not limited to:During the survey an anonymous complaint was made and included allegations that showers were not being completed and that Resident 4 was getting the least amount of care.Residents 1 and 4 were observed during the survey and appeared well groomed. No odors were detected during the survey.A review of Resident 1's shower log revealed, for the month of March 2021, had received only two showers for the month. The other times it was documented by evening staff that the resident refused his/her showers.Resident 4's shower log identified showers to be given twice weekly. The log revealed the resident received a shower at least one time per week for the month of March 2021. The other times evening staff documented the resident refused his/her shower.During an interview on 4/5/21 Staff 2 (MCC Administrator) stated the facility's policy was to place a resident on alert after two refusals and for the "next shift" to attempt the shower. There was no documented evidence that the policy was implemented for Resident 1 and Resident 4.The failure to ensure ADL assistance was consistently provided was shared with Staff 2 and no further information was received.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were reflective of the resident's status and addressed elements that were pertinent for the resident for 1 of 3 sampled residents (#1) whose evaluation were reviewed. Findings include, but not limited to:Resident 1 was identified during the acuity interview on 3/31/21 as being resistive to care, to have behaviors including resident to resident altercations and to be romantically involved with another resident. Prior to the resident's quarterly evaluation, completed on 3/13/21, the following was noted in his/her record:* On 2/9/21 s/he " ...refused [her/his] midnight meds ...while ...waking up resident for [her/his] meds ...got very upset ..." Later documentation noted resident stating " ...will take them [meds] when [he/she] wants to and at a time [he/she] wants to ..." According to the 3/01-3/31/21 MAR, the resident refused the routine Tylenol scheduled at midnight eight times. Three of the eight times occurred prior to 3/13/21;* The resident acquired two roommates, one in 1/2021 and the other in 2/2021. Both times the resident exhibited behaviors and staff documented on 2/12/21 "...has a hard time adjusting to having a roommate ..."; * On 2/8/21 a family member reported that " ...there was a referral out for a Geri-psych ..." and " ...waiting to hear back ...about appointment date ..."; and* As early as 2/28/21 the resident had displayed interest with a male resident, thinking he was his/her spouse/boyfriend. The two were identified as "kissing" and " ...has been undressing and attempting to take [male] into [his/her] apartment ..." on 3/7 and 3/8/21 respectively.The quarterly evaluation was not reflective and failed to address the following:* Mental health issues including presence of depression, thought disorders, or behavioral or mood problems; history of treatment; and effective non-drug interventions;* Personality, including how the person copes with change or challenging situations;* Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; and* Environmental factors that impact the resident's behavior including, but not limited to:(A) Noise. (B) Lighting. (C) Room temperature. The failure to ensure the quarterly evaluation was reflective of the resident's status and addressed all pertinent elements was discussed with Staff 1 (ALF Executive Director) and Staff 2 (MCC Administrator). No further information was received.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs, provided clear caregiving instructions on how to meet their needs and were followed for 1 of 3 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to:Resident 1's room and the resident were observed during the survey and the following was noted:* A pressure relief cushion on top of shower chair and not in wheelchair;* No walker was observed in the resident's room;* Resident was observed to self-propel wheelchair with feet, was observed to transfer him/herself independently from wheelchair to bed with the use of the siderail located on the exit side of bed;* Wheeled her/himself independently to the common bathroom;* Held hands with a male resident;* Unit door had no identification of a "LEAF" to note fall risk; and* Not observed to wear eye glasses.The resident's current service plan, dated 3/18/21, failed to be reflective, provide clear caregiving instructions and to be followed in the following areas:* Identified the use of walker to transfer into/out of bed and for toilet use;* Failed to identify the resident's ability to propel wheelchair independently;* Identified the resident as being resistive to care and having "good" and "bad" days. Clear caregiving instructions on what constituted a good day versus a bad day was lacking clear instructions on how to respond;* No information on the resident's ability to cope with changes, such as roommates;* Failed to identify resident's ability to respond to urges to take her/himself to the bathroom independently;* No information regarding the resident's attraction to a male resident, and relationship boundaries;* Identified as verbally aggressive. There was a lack of clear interventions including possible triggers, and how to deescalate;* Not updated to reflect outside services including PT, Geriatric-psychiatrist;* Identified the use of eye glasses;* Risk for falls and identified "LEAF" logo outside unit door;* Instructed staff to watch for non-verbal signs of pain. There was no information on the non-verbal signs of pain; and* To use a pressure relief cushion while in his/her wheelchair.The need to ensure service plans were reflective of resident care needs, provided clear caregiving instructions and was followed was shared with Staff 2 (MCC Administrator) during the survey. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure short term changes were evaluated, specific resident interventions determined and documented and the condition monitored with weekly progress noted until resolved for 1 of 3 sampled residents (#1) who experienced changes related to a new roommate and romantic relationship. Findings include, but are not limited to:During the acuity interview on 3/31/21, staff indicated Resident 1 had behaviors including altercations with other residents and had developed a romantic relationship with a male resident.The resident, who did not have a current roommate at the time of the survey, was observed to propel his/her wheelchair independently and was observed to hold hands with a male resident.The following was identified in the resident's record:a. As early as 1/23/21, the resident acquired a new roommate which caused the resident to have increased behaviors. The resident was placed on alert, however, an evaluation of the new roommate including resident specific interventions was lacking including residents' daily response and interaction to each other. On 1/27/21, the roommate was moved to another room.On 2/10/21 staff documented the resident was having multiple behaviors that day and the potential triggers identified was " ...dislikes new roommate ..." There was no documented evidence an evaluation had been completed prior to acquiring another new roommate including resident specific interventions and that the resident's status was monitored until resolution. On 2/12/21 a licensed nurse noted that the resident "expressed that [s/he] doesn't want to have a roommate ..." and staff reported " ...resident's behavior fluctuate ..." The alert status was discontinued at that time without clear evidence the situation was resolved. On 2/26/21 concerns were still identified with the new roommate as it was documented " ...did not want roommate in room ..." There was no further documentation after 2/26/21.b. On 2/27/21 the resident was identified to have an interest with a male resident, and believed the male resident was his/her spouse and/or boyfriend. On the evening shift staff documented that the resident was waiting in bed naked for him/her to come to the room. After 2/27/21, staff documented on the resident's behavior including hand holding, "kissing in room..." and then found both naked in bed on 3/29/21. There were instances where Resident 1 could also be verbally aggressive with the male resident which according to documentation upset him/her. Interventions utilized by staff included redirecting but also separating the two residents which would have a negative impact on Resident 1's behavior. There was no documentation an evaluation of the relationship had been completed including resident specific interventions and weekly monitoring of the interventions to determine if they were in place and effective. The failure to ensure an evaluation of the resident's status, specific resident interventions determined and documented, and the condition monitored weekly until resolved was shared with Staff 1 (Executive Director) and Staff 2 (MCC Administrator) during the survey. No further information was received.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:Fire drill and fire and life safety records were reviewed from 9/6/20 to 3/26/21. The following deficiencies were identified:* The facility failed to conduct fire drills every other month. Therefore, documentation was lacking regarding date and time of drill, location of simulated origin, problems encountered, and staff members on duty and participating;* The facility failed to relocate or evacuate residents during executed fire drills. Therefore, documentation was lacking regarding the escape route used, residents who resisted or failed to participate in the drills, evacuation time period needed and number of occupants evacuated; and* There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months.The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 2 (Administrator) and Staff 4 (Maintenance Director) on 4/1/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction to staff was provided on alternate months. This is a repeat citation. Findings include, but are not limited to:The documentation of a fire drill conducted by the facility prior to the re-visit survey revealed the following requirements were not documented:* Escape route used;* Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and* Number of occupants evacuated.On 6/15/21, the requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (ALF ED) who acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide evidence alternating evacuation routes were used during fire drills and resident evacuation levels were met. Findings include, but are not limited to:Fire and life safety records for September 2020-March 2021 were reviewed on 3/30/21 and lacked the following components:*Alternating evacuation routes during fire drills; and*Documentation of interventions and/or resolution for resident evacuation concerns identified during fire drills.The need to have all components of fire and life safety training documented was discussed with Staff 2 (Administrator) and Staff 4 (Maintenance Director) on 4/1/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to provide evidence alternating evacuation routes were used during fire drills. This is a repeat citation. Findings include, but are not limited to:Fire and life safety record was reviewed during the revisit survey and the following was not documented:*Alternating evacuation routes during fire drills.Discussion of alternative evacuation routes documented and points of safety, that may include outside the building, through a horizontal exit or other areas as determined by the local Fire Authority was discussed with Staff 1 (ALF ED) who acknowledged the findings.On 6/15/21, the need to have all components of fire and life safety training documented was discussed with Staff 1 (ALF ED) who acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 420 and C 422.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 231, C 420 and C 422.
Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 420 and C 422.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired direct care staff (#s 5, 6, 8 and 9) completed all required orientation, pre-service and competency training within required timelines, and 3 of 4 sampled direct care staff (#s 10, 11 and 12 ) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:Training records were reviewed with Staff 15 (Business Office Manager) on 4/1/21. The following deficiencies were identified:a. Staff 5 (CG) was hired 3/5/20. The following training requirements were not met:* Staff 5 did not complete pre-service training on "Family Support and the Role the Family May Have in the Care of the Resident" and "Use of Supportive Devices with Restraining Qualities in MCCs" prior to working independently; and * Staff 5 did not demonstrate competency in "Identification, Documentation and Reporting Changes of Condition" within 30 days of hire.b. Staff 6 (CG) was hired 11/16/20. The following training requirements were not met:* Staff 6 did not demonstrate competency in "Identification, Documentation and Reporting Changes of Condition" within 30 days of hire. c. Staff 8 (MT) was hired 7/17/20. The following training requirements were not met: * Staff 8 did not complete pre-service training on "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," "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 Orientation to the Resident's Service Plan," and "Use of Supportive Devices with Restraining Qualities in MCCs" prior to working independently; and * Staff 8 did not demonstrate competency in "Role of Service Plans in Providing Individualized Care," "Providing Assistance with ADLs," "Changes Associated with Normal Aging," "Identification, Documentation and Reporting of Changes of Condition," "Conditions that Require Assessment, Treatment, Observation and Reporting, " and "General Food Safety, Serving and Sanitation" within 30 days of hire. d. Staff 9 (MT) was hired on 9/21/20. The following training requirement was not met:* Staff 9 did not demonstrate competency in "Identification, Documentation and Reporting of Changes of Condition" within 30 days of hire. e. Staff 10 (CG) was hired on 6/19/17. For the most recent year from anniversary date of hire, Staff 10 completed 12.25 hours of annual in-service training, of which two hours were on dementia-related topics.f. Staff 11 (CG) was hired on 2/28/11. For the most recent year from anniversary date of hire, Staff 11 completed 14.25 hours of annual in-service training versus the required 16 hours. g. Staff 12 (CG) was hired on 5/14/13. For the most recent year from anniversary date of hire, Staff 12 completed 0 hours of annual in-service training. The need to ensure newly-hired direct care staff completed all orientation training prior to beginning job duties and pre-service training prior to working independently, and that long term direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 2 (Administrator) and Staff 15 (Business Office Manager) on 4/1/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 243, C 252, C 260 and C 270.