Sellwood Senior Living

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, and written, signed physician orders or other legally recognized practitioner orders were documented in the resident’s facility record for all medications and treatments that the facility was responsible to administer for 2 of 6 sampled residents (#s 2 and 4) who were administered medications and treatments. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 07/2011 with diagnoses including type 2 diabetes. The clinical record, dated 01/27/26 through 05/13/26, was reviewed and noted the following: The facility did not have signed prescriber orders documented in the resident’s record for the medications and treatments they were administering. On 05/19/26 at 2:15 pm, Staff 5 (Resident Service Coordinator) provided a copy of signed physician orders dated 05/19/26. The need to ensure the facility kept written, signed physician orders or other legally recognized practitioner orders in the resident’s facility record for all medications and treatments the facility was responsible for administering was reviewed with Staff 1 (ED) and Staff 4 (Resident Service Director) on 05/20/26 at 2:45 pm. They acknowledged the findings. 2. Resident 2 admitted to the facility in 12/2025 with diagnoses including pain, depression, and “excess fluid.” The resident’s MARs, dated 04/01/26 through 05/19/26, and physician’s orders were reviewed. The following was identified: a. On 03/18/26, Resident 2's physician signed an order for weekly weights. There was no documented evidence the weights were taken weekly between 03/18/26 and 04/21/26. b. On 04/08/26, the resident received signed orders to start Flonase (for allergies), loratadine (for allergies), and nystatin oral suspension (for thrush). There was no documented evidence the medications were transcribed onto Resident 1’s MAR or administered per physician's orders. c. The following medications were not available to staff for administration per documentation of waiting for the delivery: * Acetaminophen (for pain) - five times; and * Duloxetine (for depression) - 12 times. The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 4 (Resident Service Director), and Staff 5 (Resident Service Coordinator) on 05/20/26 at 1:42 pm. They acknowledged the findings.

1a. Resident 4 medications reviewed and orders requested for medication/treatments without physician-signed orders. 1b. Resident 2's weights were reviewed and assessed by the nurse to rule out nutrition risks. 1c. Resident 2 medication administration record reviewed and reconciled to ensure physician orders and medication records match. 1d. Resident 2 medications reviewed to ensure all medications are in-house 2. In-services completed on the following physician orders, and the medication ordering process will be completed by all medication technicians by 6/12/2026. Weights for the past six months reviewed and assessed on all residents will be completed by 6/6/2026. Audit performed on all resident MARS to ensure medications are in-house and medication administration records meet 3. The Nurse, Resident Care Coordinator, or designee will audit medication administration records a minimum of five days a week to ensure orders are followed, and medications are in-house. ED will review audits once a week for the next 60 days. The monthly audit of 20% of the census will be audited moving forward and addressed in Quality Assurance Meetings. 4. Nurse, RCC, and Designee will ensure audits are completed accordingly. The executive director will review audits monthly in quality assurance meetings with the clinical department.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on interview and record review, it was determined the facility failed to ensure MARs were kept accurate and included resident-specific parameters for PRN medications for 2 of 6 sampled residents (#s 1 and 2) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 02/2025 with diagnoses including nicotine dependence. The resident’s clinical record including the MAR, dated 05/01/26 through 05/18/26, and physician’s orders were reviewed. The following was identified: a. Resident 1's physician discontinued the PRN hydrocod/apap (for pain) on 04/17/26. The medication was still transcribed on the MAR. b. There were blanks with no explanation of why there was no documentation on the administration of a nicotine patch (for nicotine cessation) on 05/03/26 and 05/07/26. c. Resident 1 had three PRN medications prescribed for constipation. There were no resident-specific parameters to direct unlicensed staff on the sequential order to administer the medications. The need to ensure MARs were accurate and included resident-specific parameters for PRN medications was discussed with Staff 1 (ED), Staff 4 (Resident Service Director), and Staff 5 (Resident Service Coordinator) on 05/20/26 at 1:42 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 12/2025 with diagnoses including pain and depression. The resident’s MARs, dated 04/01/26 through 05/19/26, and physician’s orders were reviewed. The following was identified: a. There were duplicate entries transcribed on the MARs for the following medications: * Duloxetine (for depression); and * Diclofenac gel (for pain). On 04/26/26, two separate staff members initialed administering duloxetine to Resident 2 at 8:00 am. Staff could not verify if the medication was administered twice on that day or if the administration was incorrectly documented. b. There were multiple staff initials verifying that medications were administered in between dates where other staff documented that the medication had not been delivered by the pharmacy. c. Several dates were blank with no explanation relating to the following medication administration: * Acetaminophen (for pain) on 04/16/26 and 05/06/26 at 12:00 pm; and * Duloxetine on 04/03/26, 04/04/26, and 05/05/26 at 8:00 am. d. Resident 2 had two PRN medications prescribed for constipation. There were no resident specific parameters to direct unlicensed staff on the sequential order on when to administer the PRN medications. The need to ensure MARs were accurate and included resident-specific parameters for PRN medications was discussed with Staff 1 (ED), Staff 4 (Resident Service Director), and Staff 5 (Resident Service Coordinator) on 05/20/26 at 1:42 pm. They acknowledged the findings.

1a. Resident 1’s discontinued prn has been removed from MAR. 1b. Resident 1’s mars removed and holes for past 30 days have been followed up on. 1c. Resident 1’s prns reviewed and assessed to ensure parameters in place. 1d. Resident 2’s mars reviewed and duplicate orders removed. 1e. Resident 2’s mars was reviewed for the past 30 days and missing documentation was assessed. Mars was updated. 2. In-service on medication administration documentation and parameters will be completed by 6/12/2026 with all medication technicians. Nurse, RCC, and Designee will complete a full audit on MARS to ensure PRN parameters are in place and duplicate orders have been removed from the record. 3. Nurse, RCC, and Designee will review orders a minimum of five times a week to ensure orders have been transcribed, have parameters if needed, and ensure duplicates are removed through triple check system. A monthly audit of 20% of the resident census will be audited moving forward and addressed in Quality Assurance. 4. Nurse, RCC, and Designees will ensure audits are completed accordingly. The executive director will review audits monthly in the quality assurance meeting with the nursing department.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

Based on interview and record review, it was determined the facility failed to ensure an adequate number of direct care staff on the overnight shift to meet the 24-hour scheduled and unscheduled needs of each resident and failed to meet the fire safety evacuation standards as required by the fire authority. Findings include, but are not limited to: The facility’s acuity-based staffing tool was reviewed on 05/20/26 at 9:50 am. The posted staffing plan indicated there were two direct care staff scheduled for each overnight shift. The acuity interview on 05/18/26 indicated multiple residents on the second through fourth floors required the assistance of one care staff for transfers and wheelchair mobility. 1. Staffing schedules showed the facility was without a MT from 2:00 am until 6:00 am on the morning of 05/06/26. On 05/19/26 at 9:50 am, Staff 1(ED) was unable to verify through timecard records that a MT was in the facility on 05/06/26 between 2:00 am and 6:00 am. Additionally, she stated staff were permitted to leave the facility for their unpaid breaks, which could take up to 30 minutes, during which time only one direct care staff was available to address the scheduled or unscheduled needs of the residents on night shift. The facility failed to meet the scheduled and unscheduled needs of each resident during that time. 2. At the time of the survey, 05/18/26 through 05/20/26, the facility was home to 77 residents. The facility consisted of four floors with three exit stairwells on either end and midway between. In an interview on 05/19/26 at 1:50 pm, Staff 8 (CG) stated there were between eight to ten residents on floors two through four who used a wheelchair for ambulation or who had mobility impairments that would necessitate use of an evacuation transfer sheet or stair chair to descend the stairs. The evacuation sheets required two staff, and the stair chair required one to two staff to operate, depending on the size of the resident. Interviews between 05/18/26 and 05/20/26 with direct care staff indicated not all staff were aware of the procedure for evacuating residents who used wheelchairs to ambulate or were unable to negotiate the stairs if there was a need to move them to a different floor of the building or outside. A stair chair or evacuation transfer sheet was available on all floors in Exit Routes Two and Three but Exit Route One only had a stair chair on the second floor and no evacuation devices on the third or fourth floors. Staff 12 (CG) stated she had worked at the facility for two years and had never relocated residents and had not been educated in how to use the stair chair or evacuation sheet to move residents down the stairs. On 05/20/26 at 9:50 am, Staff 1 (ED) reported there hadn’t been a full evacuation of the building to a designated point of safety outside of the building in the last two years. Staff 1 acknowledged the facility was not able to demonstrate that two care staff were enough to meet fire evacuation standards, since evacuation under these circumstances had never practiced. The need to ensure there were an adequate number of direct care staff on the overnight shift to meet the 24-hour scheduled and unscheduled needs of each resident and meet fire safety evacuation requirements was discussed with Staff 1 on 05/19/26 at 11:20 am. She acknowledged the findings.

1. ABST tool and service plan will be reviewed to ensure they reflect each other. Continuing to interview, hire, and train appropriate staff to meet staffing requirements for scheduled and unscheduled needs. 2. Community will continue to hire and train appropriate staff to meet the needs of our residents to meet the needs of the ABST with compliance by 7/31/2026. 3. ED or designee will review ABST and staffing to five days a week to ensure staffing is appropriate. 4. ED or designee will ensure audit and compliance weekly/monthly and as needed.

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.

Based on interview and record review it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC). The findings include, but are not limited to: Fire drill records from 11/2025 to 04/2026 were reviewed and identified the following: 1. Fire drill records lacked one or more of the following required components: * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * The evacuation time period needed; * The number of occupants evacuated; * Alternate exit routes used during fire drills to react to varying potential fire origin points; and * Staff failed to provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. 2. Because the facility failed to document problems encountered with residents who failed to participate in the fire drills and to provide fire evacuation assistance from the building, the facility was unable to verify the ability to meet the applicable evacuation level or document what immediate changes were made to ensure the evacuation standard was met. The need to ensure the facility conducted and documented fire drills in accordance with the OFC was discussed with Staff 1 (ED) on 05/19/26 at 10:12 am. She acknowledged the findings.

1. Fire Drills with required documentation will be performed monthly on alternate shifts. 2. ED/MD reviewed Oregon Fire Codes for drills. 3. ED and a designee will review monthly drills to ensure documentation includes escape routes used, problems encountered, evacuation time periods, and the number of occupants evacuated recorded. 4. ED/MD will ensure that monthly drills meet the required documentation.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

Based on interview and record review, it was determined the facility failed to ensure a written record of residents’ fire and life safety instructions and procedures within 24 hours of admission was kept and residents were re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. The findings include, but are not limited to: Fire and Life Safety records were reviewed on 05/18/26 at 10:53 am and the following was identified: Resident 5 moved into the assisted living in 02/2026. The resident received a handbook upon moving in that included some fire and life safety instruction. However, the handbook lacked instructions for evacuation methods and designated meeting places inside or outside of the building. During an interview on 05/19/26 at 10:20 am, Staff 1 (ED) reported “I will say, I'm aware of this and know we need to do better with this. I know we discuss it quarterly, but we don't do a good job with documenting what we discussed.” The need to ensure a written record of residents’ fire and life safety instructions and procedures within 24 hours of admission was kept and residents were re-instructed, at least annually, was discussed with Staff 1 on 05/19/26 at 10:53 am.

1. Resident 5 has been educated on evacuation routes, and the service plan has been updated. 2. ED or designee will ensure all current residents have received fire and life safety instructions, and service plans reflect this. ED or designee will ensure new residents receive instructions on life and safety fire training within 24 hours of admission. 3. ED or designee will audit 20% of the census monthly to and review in the Quality assurance meeting. 4. ED, MD, and/or designee will ensure audits are completed accordingly.

Based on observation, interview, and record review, conducted during a site visit on 02/03/25 and 02/12/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 2 of 3 sampled Residents (#s 1 and 3). Findings include, but are not limited to: The facility utilized the ODHS ABST, and the census was 82. There were 35 residents who were not updated in the ABST as required, and 2 of 3 sampled Residents' (#s 1 and 3's) service plans and ABST profiles did not match regarding services and acuity. Resident 1 was not updated in the ABST. His/Her service plan, dated 01/19/25, indicated s/he was a total assist with dressing and toileting. There was no time assigned in the ABST for either task. The service plan indicated Resident 1 was independent with the use of the call pendant. The ABST had no task time assigned for staff to respond to call lights. Resident 1 was unavailable for interview regarding his/her care needs. Resident 3 was not updated in the ABST. His/Her service plan, dated 01/19/25, indicated s/he required one person total assist with all bathing/showering needs, but later in the service plan stated s/he was independent with bathing/showering. There was task time assigned in the ABST for assistance with bathing. On 02/03/25, Resident 3 stated s/he required assistance with bathing and sometimes lower extremity dressing. The facility's posted staffing plan indicated for day and swing shifts, there were two Med Techs (MTs) and three Caregivers (CGs) scheduled, for night shift, there was one MT and one CG scheduled. On 02/03/25, there were two MTs and three CGs working day shift. Staff schedules, dated 01/28/25 through 02/03/25 indicated the facility did not staff according to their posted staffing plan for two of 21 reviewed shifts. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 1 and 3. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (LPN Wellness Director), and Staff 3 (Resident Service Director) on 02/12/25.

10 Tag info Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/03/25 and 02/12/25.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health HS: Hours of sleep LPN: Licensed Practical Nurse MT:            Medication Technician or Med Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse SP: Service plan SPT: Service Planning Team TAR: Treatment Administration Record

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 04/25/24 at 11:10 am, the kitchen was observed to have the following concerns: * Two trays of uncovered desserts were stored on a rolling cart in the walk in refrigerator, creating potential cross contamination; * Floors throughout the kitchen underneath counters, sinks, stove/grill and dishwashing areas, including corners, had debris and black matter build-up; * Dishwashing area - the wall and caulking behind the spray hose sink had a build-up of black matter; * The dishwashing machine sides and top had debris and drips/spills;   * The walk-in refrigerator ceiling in front of fans had a build-up of dust, creating potential for cross contamination; * The walls behind and beside the stove/grill had grease drips; and * Ceiling lights had missing covers in dishwashing area, prep area, and dry storage. The areas of concern were observed and discussed with Staff 1 (Director of Dining Services) and discussed with Staff 2 (Executive Director). The findings were acknowledged.

1A.  Items identified were covered.  Staff audited and covered any/or additional items identified. 1B.  Kitchen floor has been cleaned including underneath sinks, stove/grill, and dishwashing areas/corners. 1C.  Caulking behind the spray hose sink has been re-caulked.   1D.  Dishwashing machine sides and top have been cleaned. 1E. The Walk-in refrigerator ceiling in front of the fans has been cleaned 1F.  Walls behind stove/grill has been cleaned. 1G.  All ceiling lights without covers have covers. 2A.  All dietary staff in-service on Proper food storage and transport procedures. 2B.  Daily, weekly, and monthly training of cleaning schedules training provided to all dietary staff. 2C.  Annual training on food storage/transport policies will be provided. 3. The Dietary Manager or designee will audit to ensure daily, weekly, and monthly cleanings are completed accordingly daily for the first 30 days.   The dietary Manager or designee will audit cleaning logs bi-weekly for post first 30 days for the next 60 days. The dietary Manager or designee audits cleaning logs once a week post 90 days. 4. The Dietary Manager will ensure audits are completed accordingly.  The Executive Director will review daily, weekly, and monthly cleaning log audits weekly for the first 90 days and then monthly post 90 days.

The findings of the kitchen inspection, conducted 04/25/24, 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.

The findings of the re-visit to the kitchen inspection of 04/25/24, conducted on 07/02/24, are documented in this report. The facility was found 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 service plans provided clear direction regarding the delivery of services for 2 of 6 sampled residents (#s 2 and 3). Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2021 with diagnoses including kidney failure and was receiving dialysis services. The service plan dated 05/10/23 lacked clear direction to staff in the following area: * Fistula care and safety. On 08/31/23, the need to ensure service plans provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC). They acknowledged the findings. 2. Resident 3 was admitted to the facility in 05/2021 with diagnoses including bradycardia, chronic diastolic congestive heart failure, and acute respiratory failure. Observations were made of the resident's care on 08/29/23. Interviews with facility staff and the resident were conducted. The current service plan dated 07/03/23 was reviewed. Resident 3's service plan lacked clear instructions to staff in the following areas: * Non-pharmaceutical interventions for pain, including how Resident 3 expressed pain or discomfort; and * Oxygen equipment precautions and instructions for proper maintenance. The need to ensure the service plan provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC) on 08/30/23. They acknowledged the findings. No further information was provided.

Tag C260 Resident #2 Service plan will include bleeding precautions, s/s infection, staff/med-tech, LPN, RCC or RN will monitor and record steps in first aid and RCC or LPN will review records quarterly. Tag C260 Resident #3 Staff will interview resident for non-pharmaceutical interventions such as massage, deep breathing, distraction, music therapy, etc. interview will be included in each service plan. RCC will review service plans prior to admission, within the first 30 days and quarterly. Oxygen Equipment: Staff will include oxygen equipment instructions, name of the company and phone # in service plans if applicable. This practice will be extended to all residents who are currently in use of oxygen. The staff will be trained on related policies and procedures to insure regulation compliance.

2. Resident 4 was admitted to the facility in 04/2019, with diagnoses including major neurocognitive disorder, stage 3b kidney disease, and history of diverticulitis with abscess. Review of progress notes indicated Resident 4 experienced the following changes of condition between 07/21/23 and 07/28/23: * 07/21/23 Resident 4 returned from a five day hospitalization for diverticulitis, a TSP was completed informing staff "GI problems, UTI, new med changes"; * 07/22/23 Resident 4 was sent back to the hospital due to "painful sore throat, unable to swallow and complaining of severe pain" and returned on 07/23/23 with new diagnoses of pharyngitis (inflammation of the back of the throat) and dehydration; and * 07/28/23 Alert note "res requested to be changed in bed and have meals in bed as well...res states isn't able to walk or stand." The hospitalizations, new diagnoses, med changes, and rapid decline in mobility constituted a significant change of condition. There was no documented evidence the facility evaluated the resident and referred to the facility nurse for assessment. In interview on 08/30/23, Staff 17 (RN Consultant) confirmed she had not been notified of Resident 4's change of condition and had not completed an RN assessment. The need to ensure the facility RN was notified when a resident experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC) on 08/31/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate the resident, refer to the facility RN, and update the service plan as needed when a resident experienced a significant change of condition, for 2 of 2 sampled residents (#s 1 and 4). Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2009 with diagnoses including mild major neurocognitive disorder, chronic pain syndrome, heart disease and generalized anxiety. Review of the record indicated Resident 1 fell and sustained a right wrist fracture in 05/2023. Interviews with Staff 2 (LPN) and Staff 3 (RCC) confirmed the resident needed increased staff assistance with ADLs following the injury. The wrist fracture and increase in care needs represented a significant change of condition for which the facility was required to notify the facility RN. There was not documented evidence the facility notified the facility RN of Resident 1's wrist fracture. In interviews on 08/30/23, Staff 3 and Staff 17 (RN Consultant) confirmed Staff 17 was not notified of Resident 1's significant change of condition. The need to ensure the facility RN was notified when a resident experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 2 and Staff 3 on 08/31/23. They acknowledged the findings.

C270 - Significant Change in Condition. Resident #1 & #4: Significant Change of Condition will be reflected promptly. The service plan will be updated and change of condition will be reflected. The LPN or RCC we will notiify the RN consultant in a timely manner and addressed accordingly via email, phone, text. Will be consulting with our IT department to create a Change of Condition digital form to be use in our AL ADVANTAGE platform. Until then, we are create a Change of Condition Log that will be monitored weekly by the RCC or LPN. The staff will be trained on related policies and procedures to insure regulation compliance.

Based on interview and record review, it was determined the facility failed to have a system for tracking controlled substances, for 1 of 2 sampled residents (#1) who was administered narcotic medications. Findings include, but are not limited to: Resident 1 was admitted to the facility in 09/2009 with diagnoses including mild major neurocognitive disorder, chronic pain syndrome, heart disease and generalized anxiety. The resident had an order for oxycodone 15 mg immediate-release tablet - take one tablet every three hours as needed for pain. Between 08/01/23 and 08/27/23, the Controlled Substance Log Book indicated staff signed as having removed an oxycodone pill from locked storage 62 times. However, the MAR, during that same time period, indicated the resident was administered the medication only 34 times. This was a discrepancy of 28 pills. The log book documentation and the MAR were reviewed on 08/30/23 with Staff 2 (LPN) and Staff 14 (CG/MT). They acknowledged the discrepancy. The discrepancy between the log book and the MAR was reviewed with Staff 1 (ED), Staff 2 and Staff 3 (RCC) on 08/31/23. Staff 3 stated she believed, based on the resident's pattern of use, that the medications had been administered to the resident but that staff had failed to document the administrations on the MAR. Staff 2 agreed and said the facility would address the lack of documentation with the appropriate staff.

C302- Controlled Substance Log Book will match digital MAR moving forward. #3Physician order will be carried out as prescribed and be reviewed by staff: ED, LPN, or RCC. #5 Physician order will be followed and medication given within perameters and as prescribed and reviewed by ED, LPN, or RCC LPN or the RCC will regularly check documentation in the MAR vs. the narcotic book for accuracy. We will create a log for LPN and RCC to record accuracy narcotic documentation. This will me monitored at the monthly med-tech meeting. Implicated staff will be addressed and re-trained on documentation and be asked to demonstrate the correct policy. All staff will be trained for narcotic documentation at the next all clinical staff training on Sept. 28, 2023

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#1) who was administered as needed narcotic medication. This is a repeat citation. Findings include, but are not limited to: Resident 1 was admitted to the facility in 09/2009 with diagnoses including mild major neurocognitive disorder, chronic pain syndrome, heart disease and generalized anxiety. Resident 1 had a physician order for Oxycodone 15 mg immediate-release tablet - take one tablet every three hours as needed for pain. Resident 1's 11/01/23 through 11/30/23 Controlled Substance Disposition Logs and MAR were reviewed and revealed the following: Between 11/01/23 through 11/30/2023 there were 17 occasions staff signed the drug disposition log that the PRN Oxycodone was removed from the drug card. However, the MAR lacked documentation the resident received the PRN medication. Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 2 (LPN) and Staff 3 (RCC). They acknowledged the discrepancy. The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 2 and Staff 3 on 11/30/23. The findings were acknowledged.

1. RCC/LPN will check narcotic log against MARS for accurate documentation that confirm accuracy on a weekly basis. 2. Continued training will be provided by the RCC/LPN on required documentation and proper medication administration for all current medication aides on a monthly basis. 3.Executive Director/Nurse Consultant will support the community by providing weekly audits and timely actions to take place to assure compliance.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 2 sampled residents (#s 1 and 10) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. This is a repeat citation. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2009 with diagnoses including mild major neurocognitive disorder, chronic pain syndrome, heart disease and generalized anxiety. The resident's physician orders, the Controlled Substance Disposition logs and the MAR, dated 02/01/24 through 02/27/24 were reviewed. Resident 1 had a physician order for hydromorphone 2 mg - take one tablet by mouth every three hours as needed for pain. Between 02/01/24 through 02/27/24, the Controlled Substance Disposition logs indicated staff signed as having removed a tablet of hydromorphone from locked storage 83 times. However, during the same time period, the MAR indicated the resident was administered the medication 49 times. This was a discrepancy of 34 pills. The controlled log documentation and the MAR were reviewed on 02/28/24 with Staff 2 (LPN) and Staff 3 (Resident Service Director). They acknowledged the discrepancies. The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 22 (ED), Staff 2, and Staff 3 on 02/28/24. They acknowledged the findings. 2. Resident 10's physician orders, the Controlled Substance Disposition logs and the MAR, dated 02/01/24 through 02/27/24 were reviewed. Resident 10 had physician orders for the following controlled medications: * Hydromorphone HCL 2 mg - take two tablets by mouth every six hours as needed for pain; * Morphine sulfate 15 mg - give one tablet by mouth twice daily for cancer pain; and * Oxycodone HCL 5 mg - give one tablet by mouth every eight hours as needed for pain. The following inconsistencies between the resident's MAR and the Controlled Substance Disposition log were identified: * Between 02/20/24 and 02/27/24, the Controlled Substance Disposition log indicated a hydromorphone tablet was removed from locked storage on 17 occasions. However, during the same period, the MAR indicated the resident was administered eight tablets. This was a discrepancy of 9 pills. * Between 02/01/24 and 02/27/24, the Controlled Substance Disposition log indicated a morphine sulfate tablet was removed from locked storage on six occasions. However, the MAR indicated the resident was administered eight tablets. This was a discrepancy of two tablets. * Between 02/01/24 and 02/21/24, the Controlled Substance Disposition log indicated an oxycodone tablet was removed from locked storage on 14 occasions. However, the MAR indicated the resident was administered six tablets. This was a discrepancy of eight tablets. The inconsistencies between the MAR and the Controlled Substance Disposition log were reviewed with Staff 22 (ED), Staff 2 (LPN) and Staff 3 (Resident Service Director) on 02/28/24. They acknowledged the discrepancies. The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 22, Staff 2 and Staff 3 on 02/28/24. They acknowledged the findings.

1a.  Resident's 1 medication administration records were reviewed for the past 30 days and staff updated MARs to reflect controlled substitution logs. 1b. 1a.  Resident's 2 medication administration records were reviewed for the past 30 days and staff updated MARs to reflect controlled substitution logs. 1c. All residents' 30-day audit completed by Nursing. Staff updated errors identified. 2  In-service completed on 3/22/24.Documenting Narcotics on time in MAR and controlled substance log as well as Proper procedure for adminstering meds. All med techs have recieved the training. 3. The nurse, Resident Care Coordinator, or Designees will audit all resident medication administration records to ensure MARS reflect the controlled substitution records three times a week for the first 30 days. Bi-weekly audits for an additional 30 days and then once a week for 30 days.  A monthly audit of 20% of the resident census will be audited moving forward and addressed in Quality Assurance meetings. 4. Nurse, RCC, and Designee will ensure audits are completed accordingly. Executive Directive will review audits monthly in quality assurance with the Nursing Department.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#12) who was administered as needed narcotic medication. This is a repeat citation. Findings include, but are not limited to: Resident 12 moved into the facility in 12/2022 with diagnoses including dementia. Resident 12 had a physician order for oxycodone 5 mg, 0.5 tablets (2.5 mg) by mouth every four hours as needed for pain. Resident 12's 04/01/24 through 05/09/24 MAR's and Controlled Substance Disposition Logs were reviewed and identified the following: a. Between 04/01/24 through 05/09/2024 there were two occasions staff signed the drug disposition log that the PRN Oxycodone was removed from the drug card. However, the MAR lacked documentation the resident received the PRN medication. b. Between 04/01/24 through 05/09/2024 there were five occasions staff signed the MAR however, the drug disposition log lacked documentation that the medication was administered. Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 2 (LPN) and Staff 22 (ED) on 05/09/24. They acknowledged the discrepancy.

1A. Resident 12 MAR updated late entries. 1B. Resident 12's drug disposition log updated with late entries 2A.  In-service on Controlled Substance Management, Missed or Refused Medications, Medication Records, end of shift reporting policies provided to all Medication Technicians and clinical support staff. 2B. Medicatin Technicians will run shift EMAR prn report at end of shift and compare with aPRN shift form and narcotic log. 3A. Nurse, Resident Services Director, RN, or designee will audit narcotic log, shift form, and narcotic logs on a daily basis for the first 30 days, Bi-weekly audits will be perfomed for the next 30 days. Weekly audits will be performed 30 days post intial 60 days.  Monthly audits on 30% of residents will be completed moving forward for next six months.

2. Resident 5 was admitted to the facility in 10/2021 with diagnoses including hypertension. A review of the 08/01/23 through 08/28/23 MAR and current physician's orders revealed the following: Resident 5 had a physician order for amlodipine (to control blood pressure) 5 mg to be given once per day. If the resident's systolic blood pressure was below 120 mmHg the facility was to hold the medication. On three occasions, 08/22/23, 08/26/23 and 08/27/23, the medication was given outside the parameters when it should have been held. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC) on 08/31/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 7 sampled residents (#s 3 and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 05/2021 with diagnoses including bradycardia, chronic diastolic congestive heart failure, and acute respiratory failure. Resident 3's current physician orders and MARs from 08/01/23 through 08/28/23 were reviewed. The resident's physician orders included the following, which was received at the facility by fax on 08/05/23: * Please weigh resident and call if more than a 3 pound weight gain in a week or more than a 5 pound weight gain in a month. * Please check for swelling in legs and call if present. * Please check vital signs three times a day for the next 48 hours. Call if oxygen levels below 90% on oxygen. Please call if resident becomes short of breath and can not speak a complete sentence before taking another breath. There was no documented evidence the resident's weight was obtained, swelling in the legs was assessed and vital signs were checked three times a day for 48 hours [starting 08/05/23]. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RCC) on 08/30/23. They acknowledged the findings. No further information was provided.

C 303 Policies and procedures regarding medication management, orders,and physician directives will be followed. Follow procedure as it pertains to the policy. Policies will be reviewed with management staff, LPN, RCC, ED. Med. 03 - Med-room workflow will be reviewed and all medication staffing, Med-tech, LPN, to insure regulatory compliance for order processing. Follow-up training for med-techs as to when to notify the doctor and when to consult with facility RN for clarification if necessary. #3 - Orders ill be processed in a timely manner and we will follow Dr. orders for weight monitoring and oxygen administration according to resident specific orders. We will also call the RN for advice if needed. #5- We will insure that physicians orders are carried out as prescribed and monitored via MAR. Med. 03 - will be included in the med-tech training on September 28th. Orders to monitor such things as O2 sat, edema, vital signs, shortness of breath, and weights will be placed in the MAR for documentation. Lead med-tech will ensure that all MAR directives have been entered and adhered to by 3 p.m.daily. Oversight will be provided by the RCC and LPN.

2. Resident 4 was admitted to the facility in 04/2019, with diagnoses including major neurocognitive disorder, stage 3b kidney disease, and history of diverticulitis with abscess. Review of the MAR from 08/01/23 through 08/27/23 indicated the resident refused the prescribed carboxymethylcellulose .5% ophthalmic eye drops on 25 of 27 days. There was no documented evidence the facility notified Resident 4's physician of the multiple refusals. The need to ensure the facility notified the physician or other practitioner if a resident refused consent to an order was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner if a resident refused consent to an order, for 2 of 4 sampled residents (#s 1 and 4) with documented refusals of medications. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2009 with diagnoses including mild major neurocognitive disorder, chronic pain syndrome, heart disease and generalized anxiety. Review of the MAR from 08/01/23 through 08/27/23 indicated the resident refused the prescribed lidocaine patch (for pain) on 14 of the 27 days. There was no documented evidence the facility notified Resident 1's physician of the multiple refusals. The need to ensure the facility notified the physician or other practitioner if a resident refused consent to an order was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC) on 08/31/23. They acknowledged the findings.

C-305 - Documented Refusals #1 - Facility will notify the physician immediately via faxing the refusal form and log on newly implimented system. #4 Facility will notify the physician via fax and refusal form, and log refusal of medications. Med. 14 Refused and Missed Medication. We have implimented refusal forms on each med-cart for accurate documentation of refusal which will be immediately sent to the doctor daily. We have created a log that documents the refusal forms that will be reviewed weekly by the clincial team. The Staff will be trained on related policies and procedures to insure regulation compliance at the September 28th all staff meeting. This will be monitored by the the LPN and RCC weekly.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused consent to orders for 1 of 1 sampled resident (# 3), who had documented medication and treatment refusals. This is a repeat citation. Findings include, but are not limited to: Resident 3 was admitted in 05/2021 with diagnoses including vascular dementia. The resident's 11/2023 MAR was reviewed and revealed facility staff documented Resident 3 refused all medication and treatment orders 19 times throughout the  month. There was no documented evidence the facility notified Resident 3's physician each time the resident refused to consent to the medication and treatment orders. On 11/30/23 the requirement to notify the physician/practitioner when a resident refused to consent to orders was discussed with Staff 2 (LPN) Staff 3 (RCC). They acknowledged the findings.

1. Resident 1 physician was asked for clarification of when/how often he wants to be notified when his patient refuses his medications. 2. Resident 1 MD wants to be notified on a monthly basis of med refusals. Med Tech will send MARS for last 30 days of med refusals on or about the 28th of each month 3. All 90 day orders will be reviewd by the RCC/LPN to flag medication refusals and lack of PRN use. Fax will be sent to MD for clarification or DC of medications. 4. Med Tech will send via fax notification to MD for clarification/notification of med refusals on a monthly basis. 5. ED/Nurse Consultant will review on a monthly basis.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included dosage, route, resident-specific parameters, and instructions for PRN medications for 1 of 6 sampled residents (#1) whose MAR was reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 05/2021 with diagnoses including bradycardia, chronic diastolic congestive heart failure, and acute respiratory failure. Resident 3's MAR from 08/01/23 through 08/28/23 and physician orders were reviewed and revealed the following: a. The following PRN medications lacked resident-specific parameters and instructions, including sequential order of use: * Albuterol 0.083%/3ml (for shortness of breath); * Albuterol HFA (hydrofluoroalkane) 90mcg (for shortness of breath); and * Oxygen (for shortness of breath). b. Oxygen order lacked dosage and route for administration. The need to ensure MARs were accurate and provided dosage, route, resident-specific parameters, and instructions for PRN medications was reviewed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RCC) on 08/30/23. They acknowledged the findings. No further information was provided.

C310 Maintain Accuracy of MAR #3 - MAR will be accurate and provide accurate information regarding dosage, route, and perameters. MAR will list in detail Oxygen perameters. Staff will be retrained for all Oxygen procedures, including PRN perameters on September 28, 2023 Pharmercia will be advised to enter orders promptly per their contract. Lead Med-Tech will insure perameters have been entered by 3 p.m. daily. The RCC will oversee that this has been accomplished.

4. Resident 4 was admitted to the facility in 04/2019, with diagnoses including major neurocognitive disorder, stage 3b kidney disease, and history of diverticulitis with abscess. During review of Resident 4's MAR, it was determined the resident self-administered the following medications: * ascorbic acid 500 mg (supplement); * biotin 5,000 mcg capsule (supplement); * fluticasone 50 mcg (for allergy); and * ipratropium .03% spray (broncodilator). The most recent evaluation was dated 03/30/23, prior to Resident 4 experiencing a decline and move to palliative care. The facility failed to evaluate Resident 4's ability to safely self-administer medications at least quarterly. The need to evaluate a resident's ability to safely self-administer medications at least quarterly was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC) on 08/31/23. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 09/2009 with diagnoses including mild major neurocognitive disorder, chronic pain syndrome, heart disease and generalized anxiety. The resident had signed physician orders to self-administer the following PRN medications: * Albuterol sulfate HFA (hydrofluoroalkane) inhaler (for wheezing or shortness of breath); * Voltaren gel (topical medication for pain); and * Calcium antacid chews (for indigestion). The facility failed to evaluate Resident 1's ability to safely self-administer medications at least quarterly. The most recent evaluation was dated 10/10/22. The need to evaluate a resident's ability to safely self-administer medications at least quarterly was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC) on 08/31/23. They acknowledged the findings. 5. Resident 2 was admitted to the facility in 05/2021 with diagnoses including kidney failure. During the acuity interview on 08/28/23, Resident 2 was identified as administering some of his/her own medications. The 08/01/23 through 08/28/23 MAR and current signed physician orders identified Resident 2 was self-administering the following medications: * Aspart flexpen (insulin); * Levemir (insulin); * Glutose (for low blood sugar); and * Midodrine (hypertension). An evaluation to determine Resident 2's ability to safely self-administer medications was completed in 10/2022. There was no documented evidence of a quarterly evaluation. On 08/31/23, the need to ensure residents were evaluated at least quarterly for their ability to safely self-administer medications was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 3 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure the resident's ability to safely self-administer medications for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 6) who were reviewed for self-administration. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 05/2021 with diagnoses including bradycardia, chronic diastolic congestive heart failure, and acute respiratory failure. During the acuity interview on 08/28/23, Resident 3 was identified as self-administering some of his/her medications. This was confirmed by Staff 10 (Medication Technician) in an interview on 08/28/23. Review of the records revealed the last evaluation of Resident 3's ability to safely self-administer medications was completed on 05/23/22. In an interview on 08/29/23, Staff 3 (RCC) acknowledged no evaluation had been completed more recently for the resident, and updated evaluation was done by Staff 3 during the survey. The need to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure the resident's ability to safely self-administer medications was reviewed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 on 08/30/23. They acknowledged the findings. No further information was provided. 2. Resident 6 was admitted to the facility in 12/2020 with diagnoses including orthostatic hypotension and depression. During the acuity interview on 08/28/23, Resident 6 was identified as self-administering all of his/her medications. This was confirmed by Staff 10 in an interview on 08/28/23. Review of the records revealed the last evaluation of Residents 6's ability to safely self-administer medications was completed on 11/08/22. In an interview on 08/29/23, Staff 3 acknowledged no evaluation had been completed more recently for the resident, and updated evaluation was done by Staff 3 during the survey. The need to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure the resident's ability to safely self-administer medications was reviewed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 on 08/30/23. They acknowledged the findings. No further information was provided.

C325 Self adminstration of medication. Re-evaluate all residents with self administer assessments quarterly, four times per year. Will review quarterly and as needed by RCC or LPN #3 and #6 - The assessement for self medication was completed during the survey. #1, #2, #4 - We have completed self administer assessment which evaluates the residents ability to safely administer their own medications and have documented them accordingly. We will continue to assess and monitor quarterly.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to: The facility's ABST was reviewed and discussed with Staff 2 (LPN) and Staff 3 (RCC) on 08/30/23. They reported the ABST was populated by the Resident Assessment, which was driven by the service plan for each resident. There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using. The need to have all required ADLs on the ABST, and to ensure service plans were reflective so the ABST would be accurate, was discussed with Staff 2 and Staff 3 on 08/30/23. They acknowledged the findings. No further information was provided.

C 361 ABST Meets Tools Requirements. Revisions have been made to regulataroy compliance to the 22 elements required. These changes will be fully implimented effective 9/26/23.Proof will be provided as requested by 9/27/23

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly-hired direct care staff (#12) completed all pre-service training prior to beginning job responsibilities and providing care to residents. Findings include, but are not limited to: Staff training records were reviewed on 08/29/23. Staff 12 (MT) was hired on 07/28/23. a. There was no documented evidence Staff 12 completed pre-service orientation on the following topics: * Resident rights and values of CBC care; * Infectious Disease Prevention; and * The employee was not provided a written job description. b. The staffing schedule indicated Staff 12 had been scheduled to work in the milieu with residents during the month of August 2023. However, pre-service dementia training that was provided indicated Staff 12 had not completed the training until 08/29/23 - one day after survey requested the training records. Staff 12 failed to complete the training prior to providing care to residents. The need to ensure newly-hired direct care staff completed all required pre-service orientation and dementia care training prior to providing care to residents was discussed with Staff 1 (ED) and Staff 3 (RCC) on 08/30/23. They acknowledged the findings.

C370 Staffing requirements/training and caregiver requirements All Oregon Clinical Staff Training with regard the med-tech in question has been completed and documented. We have devised a system with our new business office manager that will not allow new hires to work the floor without all the Oregon Regulation Training. We have hired a new Business Office Manager who is implementing strict onboarding procedures and will review all staff files monthly. We have created a checklist of training that is in every employee's file.

Based on interview and record review, it was determined the facility failed to ensure 2 of  2 newly hired staff completed all required pre-service orientation and training prior to beginning their job responsibilities. This is a repeat citation. Findings include, but are not limited to: Training records were reviewed on 11/30/23 and revealed the following: a. Staff 21 and Staff 22 (Resident Aides) hired on 11/15/23, lacked documented evidence of completing the following required elements for pre-service orientation prior to beginning job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Infectious disease prevention; * Fire safety and emergency procedures; and * Written job description. b. In addition, Staff 21 lacked documented evidence of completing the following required pre-service dementia care training prior to beginning job duties: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms, including, but not limited to, reducing use of antipsychotics; * Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and * Specific aspects of dementia care and ensuring the safety of residents with dementia, including identifying and addressing pain, preventing wandering and elopement and the use of a person centered approach. The need to ensure documented evidence newly hired staff completed all required pre-service orientation and dementia care training prior to beginning job duties was reviewed with Staff 2 (LPN) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

1. Matrix created to help track the following:     Pre-Service Orientation     Resident Rights     Abuse and Reporting requirements     Fire Safety     Standard Precaution     Pre-Service Infectious Disease Prevention Training 2. BOM/ED will monitor Matrix on a weekly basis 3. New hire onboarding/orientation will take place on a scheduled week day for all dept heads to participate and train in there dept. 4. Executive Director and BOM/will meet with the new hire and review all paperwork to confim completion and sign off.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly-hired direct care staff (#12) had documentation of demonstrated competency in all required areas and had completed First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 08/29/23. Staff 12 (MT) was hired on 07/28/23. a. Staff 12 failed to have documented evidence of competency demonstrated within 30 days of hire in the following areas: * Changes associated with normal aging; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. b. Staff 12 had not completed First Aid and abdominal thrust training within 30 days of hire. The need to ensure all newly-hired staff had documentation of demonstrated competency in all required areas and had completed First aid and abdominal thrust training within 30 days of hire was discussed with Staff 1 (ED) and Staff 3 (RCC) on 08/30/23. They acknowledged the findings.

C372 Staff training and abdominal thrust, food handlers, and first aid within 30 days of hire. Said new hire caregiver/med-tech has completed all Oregon State required training and it is documented. We have hired an agency to come and teach all FIRST AID, AED, Abdominal Thrust and CPR on October 19th, 2023. This is a full day of training for all employees and offered quarterly for all employees moving forward. We have devised a system with our new business office manager that will not allow new hires to work the floor without all the Oregon Regulation Training. We have hired a new Business Office Manager who is implementing strict onboarding procedure and will review all staff files monthly. We have created a checklist of training that is in every employee's file. We have devised a system with our business office manager where new hires will not move forward with the hiring process until all their Oregon-required training is complete.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 1 of 3 long-term staff (#9) whose training records were reviewed. Findings include, but are not limited to: Annual in-service training records were reviewed on 08/29/23. Staff 9 (MT), hired on 01/28/20, lacked documented evidence of a minimum of 12 hours of in-service training annually, based on their hire date, on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, and at least six hours of dementia care training, The need to ensure long-term staff completed 12 hours of annual in-service training, including six hours of dementia care training was discussed with Staff 1 (ED) and Staff 3 (RCC) on 08/30/23. They acknowledged the findings.

C374 Annual training and other requirements All staff are being advised of continued education training per Oregon State Regulation at the next All Staff Meeting, September 28th. Each employee has received a list of training requirements for their individual status. All employees have three months to complete and update coursed that they are deficient in. Continued education will be completed and documented in employee files. Annual trainings will be documented in our mandatory monthly all-staff meetings. The Business Office Manager has created an Excel sheet including the staff roster which tracks employee certiications, training, and courses, and will be updated every month and compared to each employee file by the Business Office Manager.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code (OFC). Findings include, but are not limited to: Review of fire and life safety records for January 2023 through August 2023 identified the following: a. Fire drill records lacked documentation of the following components: * 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; and * Number of occupants evacuated. b. Because the escape route not being documented, there was no evidence alternative exit routes were used during fire drills. The need to ensure fire drills were conducted and documented as required was reviewed with Staff 1 (ED) on 08/30/23. She acknowledged the findings.

C420 A fire drill calendar has been created for 2023-24: Oct. 2023, Dec. 2023, Feb. 2024, April 2023, June 2024, Aug. 2024, Oct. 2024, Dec. 2024- Training will be held in alternate months. A Fire Drill form/log and binder will be created and updated. The form will include the date and time of day, the location of the simulated fire origin, the escape route used, problems encountered and comments relating to residents wo resisted or failed to participate in the drills. It will also include, evacuation time period needed, staff members on duty and participaing, numbers of occupants evacuated, and any alternate routes used in the drill. The new Business Office Manager and Maintenance Director will meet monthly regarding all Fire and Safety training and evacuations updating training documentation.

Based on observation and interview, it was determined the facility failed to maintain all interior areas and all equipment necessary for the health, safety, and comfort of the residents clean and in good repair.  Findings include, but are not limited to: At the time of the survey the facility did not have a maintenance director. On 08/29/23 the building tour was completed with Staff 1 (ED) and Staff 5 (Housekeeping Manager). The following issues were identified: a. The first floor "Resident Laundry" room: * Two oxygen tanks were stored unsecured; * A broken commercial coffee maker stored on the floor; * Two walkers balanced on top of a counter; and * A broken washing machine filled with black, stagnant water. b. The first floor "Laundry" room: * Hopper room fire door was pinned behind a washing machine and could not close; * Laundry room wall next to the hopper room door had cove based separated from the wall causing the exposed sheetrock to crumble; * Multiple gashes and cracks in the center of the laundry room floor creating an uncleanable surface; * Floor fan with missing safety cover and exposed blade, ceiling vent fan missing safety cover, and * Two washing machines marked "broken" and "out of order". c. Second floor "Resident laundry room": * Two broken washing machines; and * One broken dryer. d. Third Floor "Resident laundry room": * One broken dryer. The need to maintain all equipment clean and in good repair was reviewed with Staff 1 on 08/30/23. She acknowledged the findings.

C613- All Interior sufaces kept in clear and good repair. Oxygen tanks in laundry room have been removed permanently. Two walkers in the laundry room have been removed permanently. Broken washers and dryers have been removed and new ones are being ordered. The firedoor has been fixed in the laundry room and now freely opens and closes. The wall and the baseboard of the laundry room is scheduled for repair by A & J Construction Co. in October 2023 Floor fan in the employee laundry room has been thrown away. 6 washers and 6 dryers are being ordered for all the washers and dryers mentioned in the state survey findings. Our Maintenance Director will montitor all laundry rooms weekly. Housekeeping will keep a log in each laundry room for cleanliness, surfaces are in repair, and equipment in proper running order.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C302, C305 and C370.

Refer to C302, C505 and C370.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 302.

Refer to C 302.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 302.

Refer to C 302

The findings of the change of ownership survey conducted 08/28/23 through 08/31/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times

The findings of the first re-visit to the change of ownership survey of 08/31/23, conducted 11/30/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

The findings of the second re-visit to the change of ownership survey of 08/31/23, conducted 02/28/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times

The findings of the third re-visit to the change of ownership survey of 08/31/23, conducted 05/09/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times

The findings of the fourth re-visit to the re-licensure survey of 08/31/23, conducted on 07/17/24, 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 observation and interview, it was determined the facility failed to ensure the kitchen was clean and food was stored appropriately, in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 01/26/23 at 12:30 pm, the facility kitchen was observed to need cleaning in the following areas: * Floor under and around stove, oven and counter with microwave had dirt and food debris; and * Wall behind microwave had dried splatters and streaks running down to the floor. Food items not stored appropriately: * Multiple items in the walk-in refrigerator were without dates/labels:  Opened bags of cheese (no date), previously cooked hot dogs in reusable bag with white congealed fat and beginning to turn a whitish-green color (no date); leftover pasta with sauce and meat that had been covered with plastic wrap, but the wrap was split down the center with the food exposed (no date and type of meat not identified), red sauce not labeled or dated, multiple other items not labeled or dated; and * Reach-in refrigerator had multiple items not labeled or dated including sour cream and salsa. *The potentially spoiled food items were discarded by Staff 1. The areas described above were discussed with Staff 1 (Executive director) and Staff 2 (Dining Services Manager) on 01/26/23. The findings were acknowledged.

C 240 - 333-150-000 Floor under the stove, and counter with with microwave had dirt and food debris: - We cleaned the area ourselves. - We scheduled a professional cleaning from Oregon Hood Cleaning 2/17/22 at 6:30 p.m. - This area has been included on our nightly cleaning list for the cooks before closing. - This area has been included on our monthly audit form conducted by the Kitchen Manager and/or the Executive Director. Multiple items in the walk-in refrigerator & reach in refrigerator were without dates and lables and not properly sealed. - We have added "updating and monitoring dates / labels and properly sealing food" to the clean up check-list after each meal. - We have assigned employees from each shift to monitor and update dating/labeling and proper sealing of containers and foods. - Before closing the kitchen each night the kitchen staff will check all labeling and sealing of food in pantry, freezer, walk-in refrigerator and reach in refrigerator. - The Kitchen Manager will ensure that all temperatures, cleaning, and labeling protocols are being adhered to and will sign off on a weekly checklist approving of such protocols. - The Executive Director will inspect all logs and checklists weekly.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and food was stored appropriately in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The facility's kitchen was toured on 03/30/23 at 1:31 pm. a. An accumulation of food spills, splatters, loose food debris, dirt, dust and garbage was observed on, in and/or underneath the following: * Flooring surrounding microwave, two-door convection oven, griddle and stove; * Shelving under two-door convection oven; * Wire racks under two-door convection oven; * Griddle; * Stove; and * Stand-up refrigerator. b. Observation of the facility's walk-in refrigerator and pantry revealed the following foods were not covered, dated, and/or labeled appropriately: * Hard boiled eggs; * Milk products; * Cream based salad; * Large container of multiple types of cheese; * Large bag of shredded cheese; * Jelly sauce; * Individual servings of canned fruit; * Pasta; * Cereal; * Tortillas; * Rice; * Powdered sugar; * Nuts; and * Chocolate sprinkles. c. Multiple dented cans were visualized in the facility's dry storage area. During a kitchen tour with Staff 1 (ED) and Staff 2 (Dining Services Manager) on 03/30/23 at 3:00 pm, the importance of not using dented cans, the items that required cleaning, dating, labeling and covering were observed and discussed. They acknowledged the findings.

We have revamped our whole kitchen routine and timelines. Each staff member has their own checklist of things to complete while on their shifts, according to their role, Monthly, Weekly, and Daily. We scheduled an all staff inservice training on our new dining service systems and protocols for Wednesday, April 19th, 2023 and will be put in to action on April 24th, 2023. We have hired a new chef who used to be a Dining Service Manager,  who will be our health & safety supervisor. One of her duties is to check all dates and items in pantry, refrigerator, and freezer when she arrives at 10 a.m. and leaves at 7p.m. She also checks temperature logs at the beginning of her shift and the end of her shift. Each person who lables and dates food items to be stored are required to put their initials on the lable so, at the very least we know who isn't lableing. We have hired three dietary aids to help with kitchen prep, cleaning, and serving duties. We have purchased bag clips and lables to be put on all opened dry, refrigerated, and items. Fully wiping down ovens, stovetops, counters, and racks is a daily duty that is assigned to the cooks. Deep cleaning ovens, stove tops, counters and racks every Sunday is a duty that have been assigned to the cooks. We have purchased a new reach in refrigerator. We have purchased a new ice machine. I can send you the  training session packet that is being presented on April 19th, 2023 by April 24th, 2023.

Based on observation and interview, it was determined the facility failed to ensure the kitchen inspection survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240.

Refer to C240

The findings of the kitchen inspection, conducted 01/26/23, 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 to the kitchen inspection of 01/26/23, conducted 03/30/23, 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 revisit to the kitchen inspection of 01/26/23, conducted 06/02/23, 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.