Tsl Elderhealth And Living Memory Village

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

Observation of the facility cottage kitchens and facility food storage areas on 01/10/25 at 10:30 am through 3:00 pm revealed the following deficiencies:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following:

Main food storage and distribution center
* Walk in cooler floor;
* Reach in freezers;

Individual Cottage Kitchens;
* Interior of reach in refrigerators and freezers;
* Interior kitchen drawers, cupboards and cabinets;
* Cupboard/drawer where trash/compost was stored;
* Interior of oven (Mt Vernon);
* Interior of microwaves;
* Dry storage pantry floors;
* Floors in outdoor storage areas where reach in freezers located;

b. The following areas were found in need of repair:

Individual Cottage Kitchens:
* Corner cupboards and cupboards storing pots/pans, baking pans observed with damage.
* Cedar house cove base missing on the corner between fridge and dishwasher.
* Cedar house vent above stove with bent/damaged screen yeilding gaps.

c. Multiple cutting boards and cooking pots/pans were found damaged and in poor repair with nonstick coating scratched or worn off.

d. Multiple potentially hazardous food items found sored in the individual kitchen reach in refrigerators not labeled or dated. Facility is removing most food items from original manufactured packaging and not putting a use by date on the food package. Multiple items were found dated past seven days from opening or preparing and should have been discarded per rule. In the Diamond Peak house, multiple specific resident food items were found stored in the refrigerator and did not have a date opened/prepared or use by date. Multiple containers of beets were found past the expired date of 01/01/25 that was written on the containers.

e. Scoops were observed stored in bulk food items like sugar and coffee where handles touched by staff were touching the food product.

f. Package of dough was noted to be stored in the draw marked “For defrosting Meats only.” Multiple open packages of deli meats were observed stored next to and with packaging touching the Bread dough packaging. In Cedar house, a bowl of raw fish was observed stored on the top shelf above ready to eat food items and fresh fruits and vegetables.

g. Care staff were observed in all houses assisting resident with meals without protective barriers (full aprons) to minimize potential contamination between care provision tasks and meal service.

h. Care staff preparing the meals were not able to identify the sanitizing agents used to sanitize surfaces in the kitchen. Staff were unaware of the effective concentrations for surface sanitation. Multiple houses were not effectively sanitizing food thermometers prior to checking food temperatures or in between food items. One staff member was observed to not sanitize the thermometer after checking temperature of fish before placing thermometer in the dessert potentially contaminating the dessert. The fish was fully cooked and posed a minimal risk to the dessert but the practice was unsafe. Surveyor immediately provided education to the caregiver.

i. Multiple food items were found stored in cold and dry food storage that were not appropriately covered/sealed and protected from potential contamination. In Diamond Peak house, a plate of food was set aside for a resident on top of the microwave. The plate of food was not covered to protect from potential contamination or to promote palatable temperatures. In Cascades house, meal service items were noted uncovered at 12:50 pm. Lunch service begins for all houses at 12:00 pm. Staff verified they were finished serving residents lunch service. Food items should be kept covered when possible, to protect from potential contamination but also to promote hot holding temperature requirements.

j. The main food storage and distribution building does not have a dishwasher to sanitize food contact utensils/dishes. The area has an one compartment sink. Multiple cutting boards and knives were observed next to the sink. Surveyor asked staff 2 (Food and Supply Coordinator/Person In Charge) what the process was for washing and sanitizing his food contact dishes and equipment as well as other surfaces in the food distribution area. Staff 2 indicated cutting boards, knives and other food contact utensils were washed by hand in the sink observed. Staff 2 acknowledged there currently was not a sanitation step as required per rule. Staff 2 was not aware a sanitize step was required. Staff 2 was also not aware of the surface sanitation chemicals used nor the needed parts per million (PPM) to ensure effective sanitation as required per rule. Staff 2 indicated maintenance department mixed the sanitation chemicals for all the houses. At 2:45pm Staff 1 (Executive Director) was interviewed and verified the maintenance department mixed chemicals for surface sanitation. Staff 2 did not know the chemicals or PPM needed for effective surface sanitation per rule. Staff 2 indicated the maintenance director was not at the facility for surveyor to interview. Surveyor asked to be provided the chemicals used and the PPM it was being mixed to along with other written information about the sanitizer used for surfaces and food contact surfaces. At the time of this report no further information was provided to ensure chemicals used were food grade and appropriate concentrations and timelines were followed.
k. Multiple kitchens were observed to have uncontained fly trap devices stored in the food preparation and service areas. The traps were full with multiple dead insect carcasses which were clearly visible to residents, staff and visitors. Surveyor discussed this with Staff 1 who was unaware these style of insect traps were not appropriate in food preparation and service areas.
l. Staff drinks were observed stored on the counters and or in reach in refrigerators and were not of approved styles. Multiple soda bottles were noted and did not have lids, straws or handles as outlined in rule. Staff drinks must be in a secure/separate area and of the right style to minimize/prevent potential cross contamination. Staff 2 was not aware of the specific style requirements.
m. The facility was composting organic material. The individual houses did not have appropriate composting containers that had securely fitting lids to minimize access, attraction and accumulation of pests. The curbside containers utilized were not being cleaned at a frequency to minimize odor and had a great accumulation of food, dirt and debris. This practice could attract pests to the refuse area of the facilities if not maintained as outlined in rule.

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 interviews, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observation of the facility cottage kitchens and facility food storage areas during a kitchen survey revisit on 04/28/25 at 11:00 am through 1:15 pm revealed the following deficiencies:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following:

Individual Cottage Kitchens;
* Interior of reach in refrigerators and freezers;
* Interior kitchen drawers, cupboards and cabinets;
* Interior of oven (Cedar);
* Interior of microwave (Cedar);

b. Multiple potentially hazardous food items found sored in the individual kitchen reach in refrigerators not labeled or dated when opened and/or prepared. Multiple houses reach in refrigerators had foods that were past 7 days and should have been discarded. One house had salad dressing that was past the manufactures use by date. In the main walk in cooler, multiple items were found well past 7 days from preparation dates and should have been discarded. Multiple items were found not dated when prepared or portioned.

c. Staff 2 (Food distribution director/ person in charge) was not able to identify sanitizing chemical for 3 compartment sink, nor were they able to correctly identify what parts per million that sanitizer was to be to effectively sanitize dishes. Staff 2 verified, they were not checking the concentration of the chemical as it came from a dispenser. Staff 4 (Maintenance director) was interviewed at approximately 11:30 am. They indicated the maintenance department manages the sanitizer dispensers. Staff 4 verified the facility was not currently checking the sanitizer dispensers daily to ensure correct operation of the dispensers and that they were dispensing at the correct PPM for effective sanitation. Staff 4 stated that the chemical vendor comes every 28 days to ensure and check the dispensers. No process was in place to monitor effective sanitation/operation of the dispensers in between.

d. Cedar house kitchen was observed to have uncontained fly trap devices stored in the food preparation and service areas. The traps were observed with multiple dead insect carcasses which were clearly visible to residents, staff and visitors.

e. Staff member was observed portioning out food products without effective hair or facial hair restraints as required per rule. Staff 2 was not aware hair restraints were required when portioning out food products.

f. Multiple houses were observed during food service where the food items being served were not covered when not in direct use for meal service. Meal service items should be kept covered, when possible, to protect from potential contamination but also to promote hot holding temperature requirements. In Diamond peak, a plated up plate of food was noted sitting on the counter top uncovered while staff member was doing other tasks.

g. Staff was observed to drink from a water bottle stored near their work space in the distribution center. This water bottle had the twist top opener which can lead to potential contamination. In Cascade house, care staff had a regular style open coffee cup that they were drinking from. Both observed staff drinks did not have a lid or a straw as required per rule.
h. Cascade house did not have weekly or daily menu posted for residents to observe/access. The menu was in the kitchen on the board for staff to refer to. Care staff from that house were interviewed at 12:25 pm and verified the menus were not posted in a common area for residents to access. The served menu to residents did not match the posted menu.
i. Multiple items were observed stored on the walk-in cooler floor and on the main storage floor. Staff 2 indicated the facility had received multiple shipments on Friday (three days prior) and had not had a chance to put it away. Staff 2 indicated this frequently happens where stock has to be put away on Monday that was delivered on Friday related to time and staffing. Surveyor reinforced per food code food can not be stored on the floor and must be put away and up off the floor within a reasonable amount of time.
Surveyor reviewed above areas with Staff 2 and they acknowledged the identified areas. At approximately 12:45 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Assistant Executive Director) who acknowledged the identified areas.

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:

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 interviews, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observation of the facility cottage kitchens and facility food storage areas during a kitchen survey revisit on 04/28/25 at 11:00 am through 1:15 pm revealed the following deficiencies:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following:

Individual Cottage Kitchens;
* Interior of reach in refrigerators and freezers;
* Interior kitchen drawers, cupboards and cabinets;
* Interior of oven (Cedar);
* Interior of microwave (Cedar);

b. Multiple potentially hazardous food items found sored in the individual kitchen reach in refrigerators not labeled or dated when opened and/or prepared. Multiple houses reach in refrigerators had foods that were past 7 days and should have been discarded. One house had salad dressing that was past the manufactures use by date. In the main walk in cooler, multiple items were found well past 7 days from preparation dates and should have been discarded. Multiple items were found not dated when prepared or portioned.

c. Staff 2 (Food distribution director/ person in charge) was not able to identify sanitizing chemical for 3 compartment sink, nor were they able to correctly identify what parts per million that sanitizer was to be to effectively sanitize dishes. Staff 2 verified, they were not checking the concentration of the chemical as it came from a dispenser. Staff 4 (Maintenance director) was interviewed at approximately 11:30 am. They indicated the maintenance department manages the sanitizer dispensers. Staff 4 verified the facility was not currently checking the sanitizer dispensers daily to ensure correct operation of the dispensers and that they were dispensing at the correct PPM for effective sanitation. Staff 4 stated that the chemical vendor comes every 28 days to ensure and check the dispensers. No process was in place to monitor effective sanitation/operation of the dispensers in between.

d. Cedar house kitchen was observed to have uncontained fly trap devices stored in the food preparation and service areas. The traps were observed with multiple dead insect carcasses which were clearly visible to residents, staff and visitors.

e. Staff member was observed portioning out food products without effective hair or facial hair restraints as required per rule. Staff 2 was not aware hair restraints were required when portioning out food products.

f. Multiple houses were observed during food service where the food items being served were not covered when not in direct use for meal service. Meal service items should be kept covered, when possible, to protect from potential contamination but also to promote hot holding temperature requirements. In Diamond peak, a plated up plate of food was noted sitting on the counter top uncovered while staff member was doing other tasks.

g. Staff was observed to drink from a water bottle stored near their work space in the distribution center. This water bottle had the twist top opener which can lead to potential contamination. In Cascade house, care staff had a regular style open coffee cup that they were drinking from. Both observed staff drinks did not have a lid or a straw as required per rule.
h. Cascade house did not have weekly or daily menu posted for residents to observe/access. The menu was in the kitchen on the board for staff to refer to. Care staff from that house were interviewed at 12:25 pm and verified the menus were not posted in a common area for residents to access. The served menu to residents did not match the posted menu.
i. Multiple items were observed stored on the walk-in cooler floor and on the main storage floor. Staff 2 indicated the facility had received multiple shipments on Friday (three days prior) and had not had a chance to put it away. Staff 2 indicated this frequently happens where stock has to be put away on Monday that was delivered on Friday related to time and staffing. Surveyor reinforced per food code food can not be stored on the floor and must be put away and up off the floor within a reasonable amount of time.
Surveyor reviewed above areas with Staff 2 and they acknowledged the identified areas. At approximately 12:45 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Assistant Executive Director) who acknowledged the identified areas.

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:

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 interview, observation and review of records, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 240 and Z142

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

(Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

This Rule is not met as evidenced by:

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

Refer to C240.

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 observations and interviews, 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 C240 and C455

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:

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 observations and interviews, 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 C240 and C455

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:

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:

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:

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:

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, conducted during a site visit on 10/31/24, the facility's failure to comply with required staffing or staff training practices was substantiated for 1 of 1 sampled staff (#6). Findings include, but are not limited to:Compliance Specialist reviewed training documents for Staff 6 (Universal worker) who was hired on 04/30/24. Records indicated there was no documented training on service plans, orientation to the residents, or documentation showing Staff 6 had successfully demonstrated satisfactory performance in any task assigned in order to work unsupervised.In separate interviews, Staff 1 (ED) stated s/he had started working at the facility in August 2024 and was not aware of staff working without completed training. S/he stated staff were trained on reviewing service plans on their first day. Staff 1 stated Staff 6 was terminated/quit on 06/01/24.Staff 6 reported s/he had started working with residents before having any training and was left alone in the house overnight without anyone to train them. "The next time I went in, there was someone there, but [s/he] left several times during the night for about half an hour at time" and "it made me very uncomfortable with not having any training in case soemthing were to happen to one of the residents".The findings were reviewed with and acknowledged by Staff 1 on 10/31/24.The facility's failure to comply with required staffing or staff training practices was substantiated.Verbal plan of correction: Facility is now doing onboarding. Hiring/interviews are done every Tuesday and if offered a position, onboarding is scheduled right away. Every week on Thursday's LPNs teach medications, transfers, and first aid training. RCC is responsible for completing the competency check off after 3 days of training in the home.

Based on interview and record review, conducted during a site visit on 10/31/24, it was determined the facility failed to have a fully implemented and updated Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:A review of the facility's ABST and resident roster indicated all 89 residents were included in the tool and had a completed ABST evaluation. Not all resident ABST evaluations had been updated at least quarterly in the tool.A review of the ABST indicated the following:· Day shift: Willow 2.17, Redwood 1.93, Cedar 1.24, Birch 2.09, Aspen 1.96, Cascade 1.24, Diamond Peak 1.75, Mt Vernon 0.90, Mt Hood 1.70 staff needed.· Swing shift: Willow 0.12, Redwood 1.40, Cedar 0.91, Birch 0.52, Aspen 1.07, Cascade 0.74, Diamond Peak 1.16, Mt Vernon 0.66, Mt Hood 1.16 staff needed.· Nigh shift: Willow 1.12, Redwood 0.19, Cedar 0.19, Birch 1.10, Aspen 0.24, Cascade 0.35, Diamond Peak 0.66, Mt Vernon 0.16, Mt Hood 0.46 staff needed.A review of the posted staffing plan and staffing schedules for 09/25/24 through 10/31/24 indicated the following:· Day shift: two universal workers (for each home)· Swing shift: two universal workers, one lead direct care staff (for each home)· Night shift: one universal worker (for each home)· The facility was not staffing per the posted staffing plan and tool.· The facility had six residents requiring two-person assistance with transferring, rolling, or sit to stand and was only scheduling one staff in each home on night shift for Cedar, Diamond, Redwood, and Willow homes.In an interview on 10/31/24, Staff 1 (Executive Director) stated the following:· The facility was using the state ABST.· The tool generated a 24-hour staffing plan.· The tool was updated with service plan updates, new move-ins, and change of condition.· The facility had floats and shift supervisors that could go around between the nine homes.· The facility was calculating their ABST hours by dividing by twelve hours or taking an average, even though they had staff working eight hours and 4 hour shifts as well.Findings were reviewed with and acknowledged by Staff 1 during phone call on 11/05/24.It was confirmed the facility failed to have a fully implemented and updated ABST.

Based on interview and record review, conducted during a site visit on 10/31/24, it was determined the facility failed to have a fully implemented and updated Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:A review of the facility's ABST and resident roster indicated all 89 residents were included in the tool and had a completed ABST evaluation. Not all resident ABST evaluations had been updated at least quarterly in the tool.A review of the ABST indicated the following:· Day shift: Willow 2.17, Redwood 1.93, Cedar 1.24, Birch 2.09, Aspen 1.96, Cascade 1.24, Diamond Peak 1.75, Mt Vernon 0.90, Mt Hood 1.70 staff needed.· Swing shift: Willow 0.12, Redwood 1.40, Cedar 0.91, Birch 0.52, Aspen 1.07, Cascade 0.74, Diamond Peak 1.16, Mt Vernon 0.66, Mt Hood 1.16 staff needed.· Nigh shift: Willow 1.12, Redwood 0.19, Cedar 0.19, Birch 1.10, Aspen 0.24, Cascade 0.35, Diamond Peak 0.66, Mt Vernon 0.16, Mt Hood 0.46 staff needed.A review of the posted staffing plan and staffing schedules for 09/25/24 through 10/31/24 indicated the following:· Day shift: two universal workers (for each home)· Swing shift: two universal workers, one lead direct care staff (for each home)· Night shift: one universal worker (for each home)· The facility was not staffing per the posted staffing plan and tool.· The facility had six residents requiring two-person assistance with transferring, rolling, or sit to stand and was only scheduling one staff in each home on night shift for Cedar, Diamond, Redwood, and Willow homes.In an interview on 10/31/24, Staff 1 (Executive Director) stated the following:· The facility was using the state ABST.· The tool generated a 24-hour staffing plan.· The tool was updated with service plan updates, new move-ins, and change of condition.· The facility had floats and shift supervisors that could go around between the nine homes.· The facility was calculating their ABST hours by dividing by twelve hours or taking an average, even though they had staff working eight hours and 4 hour shifts as well.Findings were reviewed with and acknowledged by Staff 1 during phone call on 11/05/24.It was confirmed the facility failed to have a fully implemented and updated ABST.

The findings of the kitchen inspection, conducted 09/27/23, 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 revisit to the kitchen inspection of 09/27/23, conducted 01/26/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to:Observation of the six cottage kitchens and facility food storage areas on 9/27/23 at 11:00 am am through 3:30 pm revealed the following deficiencies:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following:* Interior of reach in refrigerators and freezers;* Hand held can openers;* White shelving in main food storage area;* Fan next to walk in cooler;* Interior and exterior of kitchen drawers, cupboards and cabinets;* In between range and counter tops;* Interior of ovens;* Interior of microwaves; and* Floors in storage areas where reach in freezers located.b. The following areas were found in need of repair:* Multiple drawers or cupboards with damaged wood (not smooth/cleanable);* Metal shelves in main food storage area rusted and corroded;* Holes under sinks in kitchenette; and* Multiple pots/pans/bowls, etc., heavily scored or peeling protective coating.c. Multiple cutting boards were found damaged and in poor repair.d. Multiple potentially hazardous food items were found not labeled or dated.e. Facility was not using pasteurized eggs for undercooked egg foods like poached or soft-fried eggs.f. Potentially hazardous foods stored incorrectly found next to or above ready-to-eat foods.g. Scoops were found stored in bulk food item bins and ice bin.h. Clean dishes were observed stored next to hand washing/prep sink without protection from potential splash contamination while drying. These dishes were also sitting next to a crock pot of food during lunch service.i. Direct care staff not able to state the correct reheating and/or cook-to temperatures for food items.j. Individual house pets were having their food bowls stored in kitchens with food left in bowls, posing a potential attractant for pests. Facility pets should be kept out of food preparation and serving areas as best as possible to avoid potential contamination of food, food preparation areas and equipment.k. Multiple direct care staff who were responsible for ensuring dishes were cleaned and sanitized were not using the identified correct cycle for sanitizing of dishes. Per interview with maintenance, the cycle that would sanitize and that staff are to be using was the heavy-duty cycle. Five of six houses were using the normal/short cycle. The facility did not have a current system in place to validate that the dishwashers were effectively sanitizing dishes.l. The facility did not have a system in place to ensure the ice makers in the house/unit freezers and water filters were cleaned and maintained per manufacturer's recommendations to ensure ice was safe to consume. Staff 17 (Maintenance Coordinator) was interviewed and acknowledged he had not changed the filters or cleaned the ice makers, and he did not know when they were last done.Surveyor reviewed above areas with Staff 2 (Food and Supply Lead/PIC) and s/he acknowledged the identified areas. At approximately 3:00 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Executive Director). S/he acknowledged the identified areas.

Based on record review and interview, it was determined the facility failed to ensure 13 of 39 staff reviewed who prepare and serve food had active food handler's certificates (#s 4 thru 16). Findings include, but are not limited to:On 09/27/23 at approximately 2:30 pm, surveyor reviewed employee records for active food handler's cards. There were 10 employees who did not have a food handler's card on file and three that were found to be expired. At 2 pm, Staff 1 (Executive Director) verified there were multiple staff that did not have active food handler's certification. Staff 1 verified that those staff duties did include preparing food to residents.

Based on observation, record review and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C240.Refer to C370.

The findings of the change of ownership survey, conducted 10/03/22 through 10/05/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with 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 sugarCG: caregivercm: centimeterED: Executive DirectorF: Fahrenheit HH: Home Health LPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration Record MCC: Memory Care Community mg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 12/04//22, conducted 03/15/23 through 03/16/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen followed food handling practices and was clean and in good repair in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: a. Observations of cottage kitchens and meals throughout campus between 10/03/22 and 10/05/22 revealed the following:* Drawers and cupboards had exposed wood, rendering the surfaces uncleanable;* Baseboards were peeling away from walls and cabinets;* Shelves of refrigerators were cracked and the bottom shelf on a refrigerator door was broken and loosely taped together;* Dry storage shelves had dust, debris and white/gray accumulation;* Debris and food splatters were noted inside and on the surfaces of refrigerators, freezers, microwaves, ovens, stoves, cabinets, and drawers;* Oven vents were observed with dust and grease build-up and/or damaged filters;* Undated and unlabeled opened foods and condiments in cabinets and refrigerators;* Red/brown spills were noted on the top of a dishwasher door;* Meat and eggs were noted on the top shelf of refrigerators; * Meats being defrosted on a counter;* Pasteurized eggs were unavailable for soft-cooked entrees;* Staff members were not properly washing their hands between dirty/clean tasks;* Staff members were unable to identify proper cooling methods, proper cooking times and temperatures, and potentially hazardous foods; * Staff members were unable to answer questions related to forborne illness, including cross contamination, how to prevent foodborne illness, and signs/symptoms of foodborne illness;* Staff were not consistently cleaning thermometers with an alcohol wipe between use;* Gloves and masks were not being properly used by staff members;* The freezer in the courtyard of Cottage D had a build-up of ice on the shelves and the coils; and* Fish stored in the freezer showed signs of freezer burn.b. Observations of the "Lower Shop Main Kitchen Supply" revealed the following:* Floors throughout had an extensive build-up of black matter;* Freezers and refrigerators had food debris on the floor and shelving; and* Undated and unlabeled food items were noted in the walk in cooler.c. During a tour of the kitchen in the Mt. Vernon cottage on 10/04/22 at 3:00 PM, the following were identified: The thermometer in the door of the refrigerator registered 44 degrees Fahrenheit, which was above the minimum temperature required to ensure food safety. There was no change to the temperature when kitchen findings were reviewed with Staff 2 (Assistant Administrator) at 4:30 PM that day. It was recommended the facility check the temperature of the refrigerator with a different thermometer. Staff 2 re-checked the temperature of the refrigerator and noted it was 44 degrees Fahrenheit. Survey directed the facility to dispose of the potentially contaminated food since the temperature of the refrigerator was above 41 degrees Fahrenheit, as it was unclear how long the temperature was above the minimum required. On 10/05/20 at 8:20 AM, Staff 2 reported the temperature of refrigerator continued to be above the minimum required, and the facility was utilizing coolers to maintain perishable items at the proper temperature while the maintenance department attempted to fix the problem. She indicated food in the refrigerator would be disposed of.Upon recheck at 1:00 PM on 10/05/22, a thermometer in the door of the refrigerator registered 38 degrees Fahrenheit. d. During a tour of the kitchen in the Willow cottage on 10/03/22 and 10/04/22 the following was noted:On 10/05/22, the refrigerator thermometer was observed to be 50 degrees Fahrenheit. Facility staff reported the temperature of the milk was 44.6 degrees Fahrenheit. Survey directed the facility to dispose of the potentially contaminated food if the temperature of the refrigerator was above 41 degrees, as it was unclear how long the temperature was above the minimum required. The facility provided a plan to keep refrigerated food for Willow in the "lower shop" walk in refrigerator until the Willow refrigerator could be repaired. The plan was approved by the survey team. On 10/05/22, the need to ensure kitchens followed safe food handling practices and kitchens were clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and were followed by staff for 1 of 8 sampled residents (# 1) whose service plans were reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in June 2019 with diagnoses including Alzheimer's disease. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 07/21/22, and progress notes dated 06/25/22 to 10/03/22 were completed. Staff indicated the resident was very stiff and frequently arched his/her body and stiffened, which had previously caused slides out of the wheelchair. The resident's service plan was not reflective and was not followed by staff in the following areas:* Foot pedals only when being moved in the wheelchair;* Seat alarm; * Ability to communicate needs; and* Use of non-skid product under the resident's cushion and bottom.The need to ensure resident service plans were reflective of current care needs and were consistently followed was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/04/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in June 2019 with diagnoses including Alzheimer's. Observations of the resident, interviews with staff, review of the service plan dated 07/21/22, and progress notes dated 06/25/22 through 10/04/22 were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:* Rash on the chest;* Weight changes;* Skin breakdown on the genitals; and* Antibiotic use after skin cancer removal.The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/04/22. They acknowledged the findings. 3. Resident 6 was admitted to the facility in August 2018 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the service plan dated 07/21/22, and progress notes dated 06/27/22 through 10/04/22 were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:* Head injury;* Blisters to the foot;* Loose stools;* Behaviors including resident altercations; and* Falls.The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/04/22. They acknowledged the findings.
5. Resident 3 was admitted to the facility in November 2019 with diagnoses including Alzheimer's and diabetes. Observations of the resident, interviews with staff and review of the current service plan, short-term service plans, incident report investigations, and progress notes dated 06/25/22 through 10/03/22 were completed. The resident experienced multiple short-term changes without documented monitoring of progress and/or effectiveness of interventions at least weekly until resolution in the following areas:* 07/01/22-Non-injury fall;* 07/17/22-Blister on right foot; and* 09/12/22-Fall with skin tear to the right elbow.The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 9 (Health Services Coordinator/LPN) on 10/05/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the RN when significant, interventions were determined, documented, communicated to staff, monitored for effectiveness, and the changes monitored at least weekly through resolution for 5 of 8 sampled residents (#s 1, 3, 5, 6 and 7). Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in February 2021 with diagnoses including Alzheimer's Disease. Review of the resident's current service plan and temporary service plans, 06/28/22 through 10/03/22 progress notes, vitals records, and weight records revealed the following: a. Progress notes on 08/20/22 and 08/25/22 stated the resident experienced falls from bed on those dates. There was no documented evidence the facility determined and documented what actions and interventions were needed for the resident following the falls. b. Review of Resident 2's weights recorded in multiple documents revealed a discrepancy in the weights entered. There was no documented evidence the facility monitored the weights and addressed the discrepancies to determine if the resident had experienced a change of condition. The need to ensure the facility addressed the needs of the resident following the falls and the weight fluctuations was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/05/22. They acknowledged the findings.
4. Resident 7 was admitted to the facility in September 2022 with diagnoses including Alzheimer's. Resident 7's record was reviewed for changes of condition and revealed the following:a. Resident 7 experienced 15 falls between 09/01/22 and 10/03/22. Incident reports, progress notes, and temporary service plans identified interventions to mitigate falls; however, the records lacked evidence that interventions were being monitored for effectiveness after each subsequent fall.In an interview on 10/04/22, Staff 1 (Administrator) and Staff 9 (Health Services Coordinator/LPN) indicated Resident 7 frequently left the campus with friends and family where s/he consumed marijuana. An intervention was put into place to include having friends and family notify the facility if the Resident consumed marijuana to ensure increased monitoring and supervision to minimize further occurrences of falls. On 10/05/22, the need to ensure interventions were monitored for effectiveness was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator). They acknowledged the findings.b. Resident 7's record indicated s/he experienced a 13 pound weight loss from 09/01/2022 to 09/15/22 which constituted a 6.3% loss in two weeks.There was no documented evidence of ongoing monitoring of the resident's weight, no documentation the weight loss was reported to the RN and there were no interventions implemented to minimize further weight loss. Resident 7 was observed independently eating lunch on 10/04/22 and breakfast on 10/05/22. The resident ate 100% of the meals provided. On 10/05/22, the surveyor requested a current weight for Resident 7. The weight was noted as 191 pounds, a 1 pound weight loss since 09/15/22. On 10/05/2022, the need to ensure residents who experienced significant weight loss were referred to the RN, resident-specific interventions were developed and communicated to staff and were monitored until resolution was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was performed for all residents who had significant changes of condition, with interventions communicated to staff and service plans updated for 1 of 6 sampled residents (#7) who experienced a significant change of condition. Findings include, but are not limited to:Resident 7 was admitted to the facility on 09/01/22 with diagnoses including Alzheimer's disease.Review of the resident's weight records from 09/01/22 through 09/15/22 showed the following:The resident experienced a 13-pound weight loss from 09/01/22 to 09/15/22, which constituted a 6.3% weight loss in two weeks. The resident weighed 205 pounds on 09/01/22 and 192 pounds on 09/15/22.There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition. Resident 7 was observed independently eating lunch on 10/04/22 and breakfast on 10/05/22. The resident ate 100% of the meals provided. A current weight was requested by the surveyor on 10/05/22; the resident weighed 191 pounds.On 10/05/22 the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.During the acuity interview on 10/03/22, Resident 4 was identified to be administered insulin injections by non-licensed staff.Resident 4's insulin administration record and MARs, reviewed from 09/01/22 through 10/03/22, revealed insulin had been given by Staff 15 (Cedar Resident Coordinator/MT), Staff 28 (Shift Supervisor/MT) and Staff 29 (Shift Supervisor/MT) on multiple occasions.The most recent periodic inspection, supervision and re-evaluation of the delegation for Staff 15, completed 08/30/22, Staff 28, completed 06/22/22 and Staff 29, completed 08/25/22, lacked documentation in the following areas:* Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable; and* Individual observation/return demonstration of competence, to include determination if the staff remained capable and willing to safely perform the task. The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 8 (Health Services Director/RN) on 10/05/22. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 1 of 1 sampled resident (#6) who had a merry walker. Findings include, but are not limited to:Resident 6 was admitted to the facility in August 2018 with diagnoses including dementia.Observations of the resident, interviews with staff, and review of the service plan dated 07/21/22 showed the resident had a merry walker s/he used when out of bed. The resident was able to stand and sit without staff assistance once assisted into the merry walker. The resident additionally ate all his/her meals while seated in the merry walker. Review of the resident's record showed the last evaluation of the merry walker was completed in November 2021. The device was not evaluated at least quarterly to determine safety and appropriateness for the resident. The need to complete an assessment and the required components for the use of devices with restraining qualities was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/04/22. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff completed first aid training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 10/04/22 and 10/05/22. The following was identified:There was no documented evidence Staff 21 (CG/MT), Staff 31(CG), and Staff 32 (CG/MT), hired 07/05/22, 07/20/22, and 08/02/22, respectively, completed first aid training within 30 days of hire.In an interview on 10/05/22, Staff 3 (HR Coordinator) reported these three staff were unable to attend a scheduled new hire orientation class and she neglected to provide the training when they were able to attend.The need to ensure all new staff demonstrate competency in all required areas within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/05/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Tours of the facility's resident cottages and common areas, conducted 10/03/22 through 10/05/22, revealed the following: Cascade:* Baseboards in common areas and bathrooms had pulled away from the wall;* Baseboards in bathrooms had an accumulation of dark matter around the top and bottom edges;* A large piece of linoleum was missing from the bathroom floor in the front of the house;* Multiple areas of the flooring had seams which had pulled apart and an accumulation of dark matter was noted at the edges;* A light in the dining room was cracked with a large piece taped back in place;* Multiple ceiling lights throughout the house had dead insects and debris inside the covers;* Storage cupboard/drawers in the back of the dining room were gouged and scraped;* Grab bars in the bathrooms had a brown/red discoloration at the edges and a white discoloration along the bar;* Flooring in the living room was gouged and scraped near the transfer pole and large scratches were noted in the flooring of the other common areas;* Multiple chair backs in the dining room had stains of varying colors, elevated table had scrapes and scratches up and down the legs and the feet of the table were seated in duct taped wrapped foam with exposed/frayed edges;* Resident 6's merry walker had exposed foam padding and frayed/torn duct tape on the upper edges;* An assist bar in the front of house bathroom was wrapped in foam and duct tape, the foam was exposed in multiple areas and the duct tape was torn and frayed;* Large chips were noted to the floor of the shower with exposed under surface; and* Baseboards throughout unit had large black streaks/scuffs.Willow:* A green couch in the living room had stains on the seating area; * Multiple ceiling lights throughout the house had dead insects and debris inside the covers;* There was a gap in the flooring where the shower stall and floor met; and* There was black tape on the front deck flooring which was frayed and peeling off. Mt. Vernon:*The main entrance doormat was taped to the floor with yellow tape, which had frayed and had partially peeled away from the floor;* The baseboard in the shower room had separated from the wall; there was a build up of brown matter in the corners of the shower stall; and the paint on the mount for the grab bar had peeled off;* Floors throughout the house had gouges, scrapes, and black smudges/streaks; and * Three green chairs and the love seat in the living room had areas on the seat cushions where the fabric had ripped. Aspen:*Chipped laminate flooring in the hallway outside Rooms 4 and 5 and in the dining room;*The finish on the piano in the living room was wearing off in places and it had chips and gouges;*There were scratches on the laminate flooring in the living room; and*There was a build-up of black matter where the baseboard met the flooring in the bathroom by the dining room.Birch:*In the bathroom connected to the laundry room, the top of the garbage can was rusted;*The fireplace cabinet under the TV in the living room was chipped along the bottom edge;*The cabinet holding the fish tank in the living room had scrapes, splinters, and exposed bare wood; and*The three-drawer cabinet in the dining room was chipped and the finish was wearing off around the handles and along the bottom edge. The environment was toured with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) during survey. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C240, C372 and C513.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff demonstrated competency in all required areas within 30 days of hire and 3 of 4 long-term staff completed a total of 16 hours of annual in-service training. Findings include, but are not limited to:Staff training records were reviewed on 10/04/22 and 10/05/22. The following was identified:1. There was no documented evidence Staff 21 (CG/MT), Staff 31 (CG), and Staff 32 (CG/MT), hired 07/05/22, 07/20/22, and 08/02/22, respectively, demonstrated competency in the following areas within 30 days of hire:* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition; and* Conditions which require assessment, treatment, observation, and reporting.Staff 3 (HR Coordinator), in an interview on 10/05/22, reported these three new hires were unable to attend a scheduled new hire orientation class in which these topics were covered, and she neglected to schedule them for individual training.The need to ensure all new hires demonstrated competency in all required areas was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/05/22. They acknowledged the findings.2. There was no documented evidence Staff 17 (Resident Coordinator/MT), hired 06/20/12; Staff 34 (CG/MT), hired 08/11/20; or Staff 35 (CG/MT), hired 07/19/18, completed the required number of hours of annual in-service training in 2021 through 2022. Training records reviewed were 6/2021 - 6/2022, 8/2021-8/2022, and 7/2021-7/2022, respectively.The need to ensure staff completed a total of 16 hours of annual in-service training was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/05/22. 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 C260, C270, C280, C282 and C340.