Timber Pointe Senior Living Community

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

Observation of the kitchen on 10/01/25 at 10:45 am through 1:30 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 or underneath the following:

* Interior of ice machine;
* Interior of ovens;
* Exterior and sides of grill;
* Interior of convection oven;
* Interior of plate warmer
* Open area/nook underneath service line
* Drain under steam table
* Oven Mitts
* Juice machine
* Window Screen
* Walk in cooler fan cages/ceiling

b. Cook was observed during lunch service and was noted to not change their gloves multiple times after touching or handling potentially contaminated items. They were observed then touch/handle ready to eat foods. The cook was seen to touch a binder holding menus that was visible soiled on the out side and a marker pen multiple times. The cook also left the line multiple times to got to other areas of the kitchen to retrieve items and did not change their gloves. The gloves the cook was wearing had visible tears in the finger tips from overuse also exposing ready to eat items they handled to their bare hands.

c. Cook was observed to set ready to eat food items on the surface of the line with visible food debris from other service items. Cook was observed to cut multiple different food items from service with the same knife. No cleaning or sanitizing step was observed between knife uses. The knife was observed and had visible food debris on the knife from multiple uses. Cook would then set the knife on the visibly soiled service line or a towel next to the line that was also visibly soiled. Cook was also observed to set clean plates for resident service on the line surface that was visibly soiled with food to serve food items and then those plates were delivered to the residents.

d. At 11:40am A larger container of gravy was observed in the walk in cooler from breakfast. The container did not feel cool to the touch. Staff 2 (Dining Director) was interviewed and indicated that items would have been placed in the cooler at around 9am. Staff 2 was asked to check the temperature of the item and it was found at 72 degrees. Staff 2 acknowledged this did not meet appropriate cooling time and temperature thresholds and that the item should be discarded. Staff 2 acknowledged the facility did not have a current system for monitoring cooling processes to ensure left overs were cooling safely. Cook was interviewed and acknowledged they did not check the temperature of the food product to ensure it had met the necessary thresholds for safe cooling. Cook acknowledged there was not a current system to track and monitor cooling process for left overs.

e. Multiple containers holding potentially hazardous as well as ready to eat food items that were used for line service were observed sitting on a cart. They were not held on ice and were open/not covered or protected from potential contamination. This was observed from approximately 10:45 am through 1:00pm. The cart was close to the dish machine area and close to an open window with observed dirt/dust debris on the screen. The area was a high staff traffic area as well. This posed potential contamination risk to the ready to eat food items.

f. Multiple Staff members preparing and/or serving food and or handling clean equipment did not have hair/facial hair effectively restrained as required.

g. Towels used for wiping/sanitizing found dirty and not stored appropriately in sanitizing solutions but random places around the kitchen.

h. Container of test strips to test sanitizing solution was found soiled and/or damaged/discolored. No sanitizing solution bucket was located on the line of service to ensure easy access for line cook to sanitize surfaces or equipment.

i. Multiple dishwashing racks were observed with items overlapping and over loaded impeding the cleaning/sanitizing agent to effectively reach all dishes/equipment during the wash and rinse cycle.

j. Facility did not have a small diameter thermometer probe for thin foods.

k. Kitchen staff members serving up soups, deserts and beverages for residents were observed wearing multiple bracelets or other jewelry.

Surveyor toured kitchen and reviewed above areas with Staff 2 (Dining Services Manager) and they acknowledged the identified areas. At approximately 1:15 pm the surveyor reviewed the areas in need of cleaning and poor practices with Staff 1 (Executive Director) and they acknowledged the areas in need of correction.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings include, but are not limited to:

During the survey, conducted 07/21/25 through 07/24/25, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.

The need to ensure the facility developed and conducted an ongoing quality improvement program that evaluated services, resident outcomes and satisfaction was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 07/24/25.

Refer to the deficiencies in the report.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement

(9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined 5 of 8 sampled residents (#’s 1, 4, 5, 7, and 8) and multiple unsampled residents were not treated with dignity and respect in a safe and homelike environment. Findings include, but are not limited to:

During the survey conducted 07/21/25 through 07/24/25 multiple sampled and unsampled residents were interviewed.

1. Resident’s 1, 4, 5, 7, and 8 required staff assistance with ADL care, including shower assistance. During interviews with the residents each expressed concerns regarding excessive wait times for assistance, including multiple times showers were not provided.

2. On 07/23/25 and 07/24/25 Resident 1 was observed before breakfast wearing a shirt with dried-on food in multiple places.

On 07/24/25 at 12:20 pm the surveyor asked Staff 9 (CG) if they had offered Resident 1 a clean shirt that morning. Staff 9 stated she had not because, “All of [his/her] shirts are probably dirty. [S/he’s] probably just putting on dirty shirts. We have lots of residents like that."

The need to ensure residents received services in a manner that promoted dignity and respect in a homelike environment was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations) and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings.

Refer to C 360.

OAR 411-054-0027 (1) Resident Rights and Protection - General

(1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right:
(a) To be treated with dignity and respect.
(b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences.
(c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided.
(d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made.
(e) To receive information about the method for evaluating their service needs and assessing costs for the services provided.
(f) To exercise individual rights that do not infringe upon the rights or safety of others.
(g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse.
(h) To receive services in a manner that protects privacy and dignity.
(i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays).
(j) To have medical and other records kept confidential except as otherwise provided by law.
(k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone.
(l) To be free from physical restraints and inappropriate use of psychoactive medications.
(m) To manage personal financial affairs unless legally restricted.
(n) To have access to, and participate in, social activities.
(o) To be encouraged and assisted to exercise rights as a citizen.
(p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence.
(q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation.
(r) To be free of retaliation after they have exercised their rights provided by law or rule.
(s) To have a safe and homelike environment.
(t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion.
(u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear direction for staff, and were consistently implemented by staff for 5 of 7 sampled residents (#s 1, 2, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2025 with diagnoses including muscle weakness.

Observations of the resident, interviews with staff, review of the resident's 04/30/25 service plan, and 04/30/25 through 07/21/25 temporary service plans and progress notes were completed. Staff indicated the resident was able to direct his/her own care. The resident required assistance with transfers and other ADL care. The resident attended most meals in the dining room and utilized a wheelchair for transportation to the meals. The resident’s service plan was not reflective, not consistently implemented, and/or lacked resident-specific direction for staff in the following areas:

* Incontinent care, toileting assistance, and supervision;
* Shower preferences and assistance;
* Self-administration of medications;
* 1 versus 2-person assistance for transfers;
* Fall and safety interventions; and
* Evacuation ability.

The need to ensure resident service plans were reflective of current care needs, were consistently implemented, and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 07/24/25. The staff acknowledged the findings.

2. Resident 5 was admitted to the facility in 06/2023 with diagnoses including diabetes.

Observations of the resident, interviews with staff, review of the resident's 07/21/25 service plan, and 04/01/25 through 07/21/25 temporary service plans and progress notes were completed. Staff indicated the resident was able to direct his/her own care. The resident required some assistance with transfers and lower extremity dressing and bathing. The resident was alert and oriented and spent most of his/her time in their apartment. The resident had a manual wheelchair, a walker, and an electric scooter for mobility. The resident’s service plan was not reflective, not consistently implemented, and/or lacked resident-specific direction for staff in the following areas:

* Toileting assistance;
* Resident sleeps in recliner, transfer assistance, and night-time needs related to recliner;
* Daytime vs nighttime compression stockings and padded leg wraps;
* Shower preferences and assistance;
* Self-administration of medications;
* Right arm limitations and pain;
* Gel cushion use;
* Chronic yeast rashes and skin injury to bottom; and
* Evacuation ability.

The need to ensure resident service plans were reflective of current care needs, were consistently implemented, and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 07/24/25. The staff acknowledged the findings.

3. Resident 1 moved into the assisted living community in 09/2019 with diagnoses including Parkinson’s disease and late-onset cerebellar ataxia (movement disorder). The resident’s service plan, dated 05/20/25, was reviewed, observations were made, and resident and staff interviews were conducted.

The resident's service plan was not reflective of the resident’s needs, did not provide clear direction to staff regarding the delivery of services, and/or was not implemented.

Resident 1’s service plan documented the following regarding walking, transfers, and bathing:

* “...requires full assistance including physical and verbal assistance with walking needs. Requires hands on assistance with helping stand up, helping use any walking devices, and helping sit down/lay down.”
* “[Resident] is independent with transfers and usually transfers in and out of [his/her] power chair without use of any assistive devices.”
* “Monitor and provide assistance as needed with bathing/showering...one person assist with set up and transfer on wet surfaces As [sic] needed assist of one for drying and dressing [Resident] is able to direct cares. Stand by assist of one male care partner or two female. [sic]”

In an interview on 07/22/25 at 10:15 am Staff 12 (MA) stated the following:

* Resident 1 was fully independent with walking and transfers;
* “Sometimes we give [him/her] showers but sometimes ....[the resident] will tell us [s/he] just took a shower.”: and
* Confirmed s/he did not know what Resident 1’s service plan said in regard to his/her bathing needs.

In an interview on 07/23/25 at 2:00 pm, Resident 1 reported s/he was supposed to get showers by staff, and when staff did not show up for a scheduled shower, s/he “managed to” shower him/herself.

Resident 1’s service plan also instructed staff to cue resident to change his/her shirt if dirty. On 07/23/25 and 07/24/25 Resident 1 was observed before breakfast wearing a shirt with dried-on food in multiple places.

In an interview on 07/24/25 at 12:20 pm Staff 9 (CG) reported, “[S/he is] probably just putting on dirty shirts,” and confirmed she had not cued the resident to change into a clean shirt.

On 07/24/25, the need to ensure service plans were reflective of the residents’ needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/25/25. They acknowledged the findings.

4. Resident 6 moved into the assisted living community with diagnoses including congestive heart failure.

Observations of the resident, interviews with staff, and review of the service plan, dated 07/15/25, and subsequent temporary service plans (TSP’s) identified the service plan did not provide clear direction to staff, including the frequency care should be provided in the following areas:

* Transfers in and out of bed;
* Use of wedges to elevate legs in bed;
* Edema and open skin concerns;
* Dressing assistance, including the use of compression stockings;
* Frequency for escorts in wheelchair;
* Frequency of showers;
* Frequency of housekeeping; and
* Frequency of laundry assistance.

The need to ensure resident service plans provided clear direction to staff including the frequency of how often care was to be provided was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations) and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings.

5. Resident 2 was admitted to the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease, hypertension, and depression.

Interviews with staff and Resident 2 and a review of the resident's current service plan, dated 06/03/25, and temporary service plans were conducted during the survey.

Resident 2's service plan was not reflective and did not provide clear direction to staff in the following areas:

* Relationship with another resident;
* Use of PRN psychotropic medication;
* Refusal of care;
* Dressing, grooming, bathing, and personal hygiene status;
* Frequency of hospice services provided;
* Environmental risk factors that impacted the resident’s behavior;
* Preference to eat meals in apartment;
* Pet living in apartment; and
* The resident's ability to care for his/her pet.

The need to ensure service plans reflected the resident care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to determine resident-specific interventions for residents following a short-term change of condition, communicate interventions to staff on each shift, and/or monitor and document weekly progress until the condition resolved for 4 of 6 sampled residents (#s 1, 4, 5, and 6) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 1 moved into the assisted living community in 09/2019 with diagnoses including Parkinson’s disease and late-onset cerebellar ataxia (movement disorder).

The resident’s progress notes, dated 04/28/25 through 07/18/25, service plan, dated 05/20/25, and temporary service plan, dated 07/08/25, were reviewed. The following was identified:

Progress notes documented the resident fell on 07/06/25 when s/he tripped over the foot pedal of his/her power chair. The resident sustained a laceration on his/her head and was sent to the hospital, returning the same day.

On 07/09/25 staff documented in the progress notes the following injuries:

* 07/09/25 – scrape on right knee; and
* 07/09/25 – bruising around left eye.

There was no documented evidence that the facility monitored the knee scrape or the bruising around the eye.

The need to ensure the facility monitored the resident at least weekly according to their evaluated needs through resolution, was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 1:50 pm. They acknowledged the findings.

2. Resident 6 moved into the assisted living community in 05/2025 with diagnoses including hypertension, atrial fibrillation, and congestive heart failure.

The resident’s progress notes, dated 05/06/25 through 07/21/25, service plan, dated 07/15/25, and temporary service plans were reviewed during the survey.

There was no documented evidence the facility determined actions or interventions, communicated the interventions to staff on each shift, and monitored the changes of condition with weekly progress noted in the resident’s record until the condition resolved, for the following short-term changes of condition:

* 05/06/25 - New move-in;
* 05/27/25 - Resident sent to the emergency room for swelling in both legs and feet. Resident returned to the assisted living the same day;
* 06/17/25 - Sent to emergency room for edema and CHF symptoms. Resident returned to the assisted living the same day;
* 06/30/25 - Progress note dated 06/30/25 noted, “resident reported to me [his/her] right wrist to mid forearm is having pain. [S/he] states it feels like the gout [s/he] had...”
* Missed medication colchicine (for gout) from 05/06/25 through 07/09/25; and
* Missed treatment fluorouracil cream (for skin condition) from 05/06/25 through 07/21/25.

The need to ensure the facility determined actions or interventions needed for changes of condition, communicated the actions or interventions to staff, and monitored the condition weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 04/2025 with diagnoses including muscle weakness.

Observations of the resident, interviews with staff, review of the resident's 04/30/25 service plan, and 04/30/25 through 07/21/25 temporary service plans and progress notes were completed.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas:

* Multiple medication changes;
* Fall with injury;
* Low oxygen saturation levels; and
* Urinary tract infection.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 07/24/25. The staff acknowledged the findings.

4. Resident 5 was admitted to the facility in 06/2023 with diagnoses including diabetes.

Observations of the resident, interviews with staff, review of the resident's 07/21/25 service plan, and 04/01/25 through 07/21/25 temporary service plans and progress notes were completed.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas:

* Multiple medication changes;
* Edema, shortness of breath, and oxygen use;
* Elevated blood sugars;
* Skin injury and rashes; and
* Fall with fracture and right arm pain.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 07/24/25. The staff acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment for 1 of 1 sampled resident (#6) who experienced severe weight gain. Findings include, but are not limited to:

Resident 6 moved into the assisted living community in 05/2025 with diagnoses including congestive heart failure (CHF). During the acuity interview on 07/21/25, Resident 6 was identified to have experienced weight gain.

Review of the resident’s clinical record and weights and vitals summary from 05/13/25 through 07/21/25 identified the following:

* 05/13/25: 157.2 pounds (weight at move-in);
* Progress notes dated 05/27/25: was sent out to the emergency room for swelling in both legs and feet and exacerbated CHF symptoms; and
* 06/01/25: 175 pounds.

The facility’s “weights and vitals summary” triggered a weight warning in the electronic health management system indicating the resident gained 17.8 pounds since 05/13/25, which was an 11.3 % severe weight gain in less than one month.

* 06/17/25: the resident was sent out to the emergency room for swelling in both legs and feet and exacerbated CHF symptoms.

There was no documented evidence an RN completed a significant change of condition assessment for Resident 6’s severe weight gain until 07/01/25.

During an interview on 07/23/25 at 11:06 am, Staff 5 (Wellness Coordinator/RN) stated she was not made aware of the weight gain until 07/01/25.

The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

This Rule is not met as evidenced by:

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 (# 2) whose MAR and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease, hypertension, and depression.

Resident 2 had a signed physician order for morphine sulfate oral solution 100 mg/5 ml, take 0.5 ml by mouth every two hours as needed for pain or shortness of breath.

Resident 2's Controlled Substance Disposition logs and MAR, reviewed from 07/01/25 through 07/20/25, identified the following:

* A 07/05/25 dose of morphine at 9:19 am was reflected on the MAR but not on the disposition log;
* A 07/12/25 dose of morphine at 12:00 pm was reflected on the disposition log but not on the MAR;
* A 07/14/25 dose of morphine at 2:15 pm was reflected on the disposition log but not on the MAR; and
* A 07/18/25 dose of morphine at 12:06 am was reflected on the disposition log but not on the MAR.

The need to ensure the facility maintained an accurate system for tracking controlled substances was reviewed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25. They acknowledged the findings.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances

(e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure written, signed physician 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 and failed to ensure all medications and treatments were carried out as prescribed for 4 of 6 sampled residents (#’s 1, 2, 6, and 8). Findings include, but are not limited to:

1. Resident 6 moved into the assisted living community in 05/2025 with diagnoses including congestive heart failure.

Review of the resident’s 06/01/25 through 07/21/25 MARs and signed physician orders noted the following medications were not administered as prescribed:

* Colchicine, give one tablet twice daily (for gout);
* Fluorouracil cream, apply twice daily (for skin condition); and
* Eliquis 10 mg, give one tablet daily (for blood thinner).

The MAR noted MA’s were documenting the colchicine and fluorouracil were not available to administer and the Eliquis was being administered 5 mg twice daily.

During an observation of the medication cart on 07/23/25, Staff 19 (MA) confirmed the Colchicine and Fluorouracil cream were not available.

During an interview with Staff 5 (Wellness Coordinator/RN) on 07/23/25 at 1:20 pm, it was confirmed the order for Eliquis was transcribed onto the MAR by the pharmacy who changed the order to twice daily dosing rather than once a day as the order was prescribed. Staff 5 confirmed there was not a signed order for twice daily dosing, and she said she would be following up with the prescriber.

The need to ensure medications and treatments were being administered as the prescriber ordered was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings.

2. Resident 8 moved into the assisted living community in 03/2024 with diagnoses including hypothyroidism.

An interview with Resident 8 and a review of the resident’s 07/01/25 through 07/24/25 MAR and signed physician orders identified the following medications were not administered as prescribed:

* On 07/04/25 and 07/11/25 - Levothyroxine 150 mcg tablet 5 days per week Sunday through Thursday (for hypothyroidism);
* Retaine mineral eye drops, one drop in both eyes every two hours. If [s/he] is sleeping wake to instill the drops (for dry eyes); and
* On 20 occasions from 07/01/25 to 07/24/25, staff noted on the MAR they didn’t follow the Retaine eye drop order because the resident was sleeping.

The need to ensure medications and treatments were being administered as the prescriber ordered was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings.

3. Resident 1 moved into the community in 09/2019 with diagnoses including Parkinson’s disease and late-onset cerebellar ataxia (movement disorder).

Resident 1’s MAR, dated 07/01/25 through 07/21/25, and corresponding prescriber orders were reviewed. The following was identified:

a. The resident had a nurse practitioner’s order for carbidopa/levodopa 25-100mg tablet two tablets by mouth three times daily at 8:00 am, 2:00 pm, and 8:00 pm (for Parkinson’s disease). The MAR documented the medication being administered every day at 8:00 am, 1:00 pm, and 8:00 pm. Staff 11 (MA) confirmed the medication was administered at 1:00 pm every day and not at 2:00 pm.

b. The resident had a nurse practitioner’s order for “Check blood pressure daily. Notify front desk to make appointment for resident with PCP if resident has blood pressure over 140/90.” The MAR documented blood pressure checks three times per day. On 18 occasions in July 2025 the resident had blood pressure readings over 140/90. On 07/24/25, Staff 23 (Business Office Assistant/Lead Concierge) reported that the system for notifying the front desk for PCP appointments was verbally or, in her absence, a sticky note. Staff 23 reported the last time she was asked to call the PCP for an appointment due to Resident 1’s high blood pressure was approximately two months prior.

The need to ensure all orders were carried out as prescribed was discussed Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 1:50 pm. They acknowledged the findings.

4. Resident 2 was admitted to the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease, hypertension, and depression

Resident 2's signed physician orders and 07/01/25 through 07/21/25 MAR were reviewed.

Resident 2's MAR indicated the resident was taking ropinirole 40 mg once daily to treat restless leg syndrome. There was no current signed order for the medication.

The need to ensure signed physician or other legally recognized practitioner orders were documented in the resident’s record for all medications the facility was responsible to administer was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer medications had an evaluation completed at least quarterly to determine their ability to safely self-administer medications for 2 of 2 sampled residents (#s 4 and 5) reviewed for self-administration. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2025 with diagnoses including muscle weakness.

During the record review for Resident 4, it was determined the resident self-administered part of his/her medications.

The resident's 04/30/25 through 07/21/25 progress notes, evaluations, physician’s orders, and the 07/01/25 through 07/21/25 MAR were reviewed.

A self-administration evaluation could not be located for the resident.

The need to ensure residents who self-administered any of their own medications were evaluated at least quarterly was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 4 (Wellness Director/LPN), and Staff 5 (Wellness Coordinator) on 07/22/25 and 07/24/25. The staff acknowledged the findings.

2. Resident 5 was admitted to the facility in 06/2023 with diagnoses including diabetes.

During the record review for Resident 5, it was determined the resident self-administered part of his/her medications.

The resident's 04/01/25 through 07/21/25 progress notes, evaluations, physician’s orders, and the 07/01/25 through 07/21/25 MAR were reviewed.

A self-administration evaluation was last completed in December 2024. Staff 1 (ED) confirmed there was no other evaluation completed more recently for the resident.

The need to ensure residents who self-administered any of their own medications were evaluated at least quarterly was discussed with Staff 1, Staff 2 (Vice President of Operations), Staff 4 (Wellness Director/LPN), and Staff 5 (Wellness Coordinator) on 07/22/25 and 07/24/25. The staff acknowledged the findings.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds

(5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

This Rule is not met as evidenced by:

Based on interview and record review it was determined the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents, per the facility’s posted staffing plan. Findings include, but are not limited to:

1. A review of the facility's posted staffing plan, staff schedule from 07/11/25 through 07/21/25, and current ABST indicated the following staffing schedule:

* Day Shift: 6:00 am- 2:30 pm – 9 direct care staff;
* Swing Shift: 2:00 pm – 10:30 pm – 8 direct care staff; and
* Overnight Shift: 10:00 pm - 6:30 am – 3 direct care staff.

A review of the facility scheduled from 07/11/25 through 07/21/25 identified 16 out of 33 shifts or 48.48% were staffed below the posted staffing plan.

2. Multiple staff and resident interviews identified concerns regarding long call light times.

Review of the call log reports for sampled Resident’s 1, 4, 5, and 7 showed the following:

* 05/17/25 through 05/27/25 - 101 calls over 20 minutes and two calls over one hour long;
* 06/08/25 through 06/21/25 - 209 calls over 20 minutes and one call over one hour long; and
* 07/01/25 through 07/20/25 - 264 calls over 20 minutes and four calls over one hour long.

On 07/23/25 at 11:25 am, Resident 7 reported that s/he had excessive call light times when calling staff to help him/her get into bed in the evening or to assist with toileting needs.

Resident 8 reported not having a shower for up to one month. Resident 8 reported “staffing issues began after [the new owners] took over.”

Multiple unsampled resident interviews also reported showers were not being provided per the resident’s service plan. Some residents reported not receiving shower assistance for multiple weeks.

During an interview on 07/21/25 at 3:40 pm, Staff 20 (MA) reported call light times “are usually more than 30 minutes long and we have a few residents that need showers that take upwards of two hours to complete, and we just can’t get to them because we don’t have enough staff.” Staff 20 further reported she was trained to answer call lights within 15 minutes.

Staff 1 (ED) stated on 07/24/25 at 1:50 pm that staff were trained to answer the call lights within 15 minutes.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents.

The need to ensure the facility was staffing sufficient staff per the posted staffing plan was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to accurately capture care time and care elements staff were providing to residents for 5 of 6 sampled residents (#s 1, 3, 4, 5, and 6). Findings include, but are not limited to:

Observations of Resident’s 1, 3, 4, 5, and 6, interviews with direct care staff from 07/21/25 through 07/24/25, and review of Resident 1, 3, 4, 5, and 6’s service plans and acuity-based staffing tool (ABST) evaluations were completed and revealed the residents’ allotted care minutes were not reflective of current needs in one or more of the 22 care elements of the ABST.

The need to ensure the ABST accurately captured the care time and care elements for all residents in each of the 22 ADL areas was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time

(1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING
(b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average.
(c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents.
(d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1).
(e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule.
(f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.
(g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to accurately capture the care time staff provided to each resident, as outlined in their individual service plans, for 3 of 3 sampled residents (#s 9, 10, and 11) whose Acuity-Based Staffing Tool (ABST) data was reviewed. This is a repeat citation. Findings include, but are not limited to:

On 11/04/25 at 11:00 am, Staff 1 (ED) provided the surveyor with ABST caregiving time detail summaries for residents #9, 10, and 11. Review of the documentation identified care time was not accurately captured for Residents 9, 10, and 11 in one or more of the following areas:

* Responding to call lights;
* Ambulation, escorting to and from meals or activities;
* Dressing and undressing;
* Grooming, such as nail care and brushing hair; and
* Resident specific housekeeping and laundry services.

The need to accurately capture care time on the resident's ABST was discussed with Staff 1 and Staff 4 (Wellness Director)/LPN). On 11/05/25 at 1:30 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in and no less than quarterly at the same time as the service plan update for 4 of 6 sampled residents (#s 2, 3, 4, and 5) and one unsampled resident. Findings include but are not limited to:

The facility’s ABST was reviewed on 06/23/24 at 1:30 pm. The following was identified:

a. Resident 3 and one unsampled resident did not have an ABST evaluation completed.
b. Resident 2, 3, 4 and 5’s ABST evaluations did not have evidence they were updated quarterly at the same time as the service plan update.

The need to ensure residents’ ABST evaluations were updated before move-in and no less than quarterly corresponding with the service plan update was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:

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

Refer to C342 and C613.

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

The facility was toured on 07/21/25. The following deficiencies were identified:

* Many of the dining room chairs had significant peeling on the vinyl seats.
* The caulking around the base of the toilet in the men’s restroom on the first floor was black.
* Carpeting in the following common areas had large dark stains: the area in front of the mailboxes, the hallway outside Room 322, and the stairwell across from Room 226.
* Carpeting in resident apartments 103, 108, 118, and 315 had large dark stains.
* Apartment 133 had a cracked window.
* The framing around the elevator on the first floor by the dining room had large areas that were gouged, splintered, and chipped, exposing bare wood and metal.

The above areas needing cleaning and/or repair were reviewed with Staff 1 (ED) on 07/22/25 and 07/24/25. She acknowledged the findings.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable

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

This Rule is not met as evidenced by:
Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:

The facility was toured on 11/03/25. The following deficiencies were identified:

* Carpeting in resident apartments 103, 108, 113, 118, 315, and 322 had large dark stains; and
* Apartment 133 had a cracked window.

The above areas needing cleaning and/or repair were reviewed with Staff 1 (ED) and Staff 8 (Environmental Services Director) on 11/04/25 and 11/05/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure each resident had the freedom and support to control his/her own schedule and activities for 2 of 2 sampled residents (#s 4 and 5) who expressed concerns related to bathing. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 04/2025 with diagnoses including muscle weakness.

The resident’s service plan indicated the resident was to have two showers a week and s/he preferred the morning. Shower sheets could not be located for two showers a week over the last month.

In interview with the resident on 07/22/25, s/he indicated assistance with showers was not provided on a regular basis. The resident felt like s/he needed to take showers when staff were available rather than his/her preferred shower time. The resident stated some weeks there were no showers offered. The resident further indicated there were not enough staff to get things done.

Review of the facility bathing schedule, and shower sheets was completed.

The weekly shower schedules showed the following:

* 06/29/25 through 07/05/25 showed the resident listed for showers on Wednesday and Sunday at 1:00 pm, and neither shower was signed as completed.
* 07/06/25 through 07/12/25 showed the resident listed for showers on Wednesday and Thursday at 1:00 pm, and neither shower was signed as completed.
* 07/13/25 through 07/19/25 showed the resident listed for showers on Thursday and Sunday at 1:00 pm, and only Thursday was signed as completed.

The need to ensure each resident had the freedom and support to control his/her own schedule was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 3 on 07/21/25 and 07/24/25. The staff acknowledged the findings.

2. Resident 5 was admitted to the facility in 06/2023 with diagnoses including diabetes.

Review of the resident’s 06/11/25 evaluation and 07/21/25 service plan indicated the resident was to receive daily bathing, and the resident’s service plan indicated the resident was to have two showers a week. No resident preference on time was noted in the evaluation or service plan.

In an interview with the resident on 07/21/25, s/he indicated showers do not happen on an actual schedule. The resident felt like s/he needed to take showers when staff were available rather than his/her preferred shower time. The resident stated s/he went close to three weeks with no shower before s/he finally complained. The resident was told s/he was not on the shower schedule and that was why nobody came to offer or check in on his/her showers. The resident further indicated there were frequently not enough staff working to get the showers done.

Review of the facility bathing schedule and shower sheets was completed.

The weekly shower schedules showed the following:

* The 06/29/25 through 07/05/25 schedule did not have the resident listed at all.
* The 07/06/25 through 07/12/25 schedule showed the resident was written in for one shower on 07/10/25; no time was indicated.
* The 07/13/25 through 07/19/25 schedule did not have the resident listed at all.

The need to ensure each resident had the freedom and support to control his/her own schedule was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 3 on 07/21/25 and 07/24/25. The staff acknowledged the findings.

OAR411-004-0020(2)(i) Individual freedom & Support: Activities

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(i) Each individual has the freedom and support to control his or her own schedule and activities.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were treated with dignity and respect and failed to provide a safe and homelike environment related to courtyard access for 2 of 2 sampled residents (#s 1 and 2) and non-sampled residents. Findings include, but are not limited to:

Observations of the resident courtyard on 12/02/24 and 12/03/24 showed the following:

* There were double doors on each side of the dining room which led to the outdoor courtyard, gazebo, and resident smoking area.
* The doors remained locked throughout the day/evening. Residents who went out to the courtyard had to utilize their key to come back into the facility.
* The main entrance was unlocked throughout the day and early evening. The door opened automatically when people approached.
* Multiple residents utilized the smoking area and courtyard throughout the day/evening. Residents who were in wheelchairs struggled to get the door unlocked and opened and to maneuver their wheelchairs through the doorway.
* Staff assisted with opening the door if they were nearby and observed residents struggling.
* Resident 1 had multiple scabbed areas on his/her hands and feet.

Interviews conducted between 12/02/24 and 12/03/24 showed the following:

Resident 1 indicated s/he had a very difficult time getting in and out the door on his/her own. The door did not have an automatic opening feature. The resident indicated it was most difficult getting back in because the doors were locked. S/he had to get the door unlocked with his/her key and then try to pull the door open, hold it, and drive his/her electric wheelchair through the door. Resident 1 indicated s/he had bumped hands and feet repeatedly and had several scrapes, scabs and/or bruises from trying to get through the door. The resident went outside frequently to the smoking area and found it “extremely frustrating” to be unable to get in and out the door on his/her own without some kind of issue.

Resident 2 indicated s/he went outside throughout the day. S/he stated the doors were all locked so must take his/her key with him/her to get back inside or would need to come around to the front door, which would be unlocked. The resident stated s/he sometimes went out the front and around to his/her preferred location and other times went out the dining room doors or the door at the end of the hall. Resident 2 stated s/he usually went out in his/her electric wheelchair but had gone out in the manual wheelchair as well. The resident indicated it was difficult to get in and out the doors in the dining room as well as the doors at the end of the halls. The resident indicated s/he had a fall from his/her wheelchair several weeks ago trying to get back in one of the locked doors.

Non-sampled residents from the group interview and general observation of the facility indicated the doors were all kept locked, required their keys to get back into the facility, and were difficult to maneuver while trying to get back into the facility. Two residents indicated issues specifically with the front door being locked at night, as well.

Staff 18 and 19 (CGs) indicated the doors were kept locked for safety. The residents all had keys and also had call pendants to wear. The staff further indicated if a resident needed help coming in or while they were outside, they could just push their pendant.

Staff 1 (Administrator) indicated the doors were kept locked for safety, as there had been transients trying to enter the facility. All the residents had keys and could use their pendants for assistance as well. Staff 1 indicated they would look at other options for the doors.

Staff 3 (Wellness Director/LPN) indicated Resident 1 had several skin issues related to bumping into multiple areas in the facility. Staff 3 further indicated Resident 2 did have a fall out of his/her wheelchair while trying to get back into the facility but was unsure if it was from the courtyard or a door at the end of the hall.

The need to ensure residents were treated with dignity and respect, had a safe and home like environment and were able to easily access the courtyard and outdoors without creating an increased risk for injury was discussed with Staff 1, Staff 2 (Wellness Coordinator/RN), Staff 3, and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure evaluations were reflective of the needs and current condition of 2 of 7 sampled residents (#s 1 and 5) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 09/2023 with diagnoses including multiple sclerosis, myasthenia gravis, post-polio syndrome, and history of malnutrition.

The resident's most recent evaluation, dated 11/06/24, was reviewed, interviews were conducted, and the resident was observed. Multiple areas of the evaluation did not describe Resident 6's current physical and mental status, environmental factors which helped the resident function at his/her optimal level, and/or were not reflective of the resident's current condition, including:

* Hospital admission within the past 12 months;
* Non-pharmacological interventions for pain;
* Behaviors, including suicidal ideation;
* Confusion; and
* Level of assistance required with transfers, ambulation, grooming, dressing, personal hygiene, and meals.

The need to ensure evaluations described resident's physical health status, mental status, and the environmental factors that helped the resident function at their optimal level, and were reflective of the current needs and condition of the resident, was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) at 2:05 pm on 12/05/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in August 2022 with diagnoses including chronic obstructive pulmonary disease.

The resident’s most recent smoking evaluation, dated 10/31/24, observation notes 09/02/24 through 11/24/24, and alert charting notes 09/03/24 through 12/02/24 were reviewed.

Observation notes in September 2024 and October 2024 reflected five occasions in which the resident was slumped over or asleep in his/her wheelchair while outside in or near the smoking area. On one occasion the resident dropped his/her cigarette onto the blanket on his/her lap. Staff observed this and intervened, and no injury was sustained. The resident was a frequent smoker, and no burn injuries were documented for the resident during the look-back period. Additionally, no burn holes had been noted to his/her clothing or lap blanket.

Additional observation notes for the month of October 2024 reflected four occasions in which the resident was found to be smoking in his/her apartment or was suspected of smoking in the facility.

The smoking evaluation did not accurately reflect the resident’s recent history of nodding off while outside, dropping a cigarette into their lap, and smoking in his/her apartment and/or elsewhere within the facility interior.

In an interview on 12/05/24, Staff 2 (Wellness Coordinator/RN) indicated the resident’s drowsiness was strongly related to low oxygen saturations and some medication issues at the time. The resident currently was doing much better with oxygen compliance, and the sleepiness and nodding off had improved.

In an interview on 12/05/24, Staff 3 (Wellness Director/LPN) indicated the resident had experienced a significant change at the time the smoking evaluation was updated. The resident currently was not nodding off while smoking and was not attempting to smoke indoors. Staff 3 understood the need to complete an updated smoking evaluation, with all areas of potential concern addressed regarding the resident’s ability to independently smoke at the time of a significant change or other assessment.

The need to ensure smoking evaluations contained all pertinent information related to the resident’s safe smoking ability was discussed with Staff 1 (Administrator), Staff 2, Staff 3, and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. The staff 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, provided clear direction regarding the delivery of services, and services were implemented for 5 of 7 sampled residents (#s 1, 2, 5, 6, and 8) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 07/2021 with diagnoses including heart failure and atrial fibrillation.

The resident's current service plan, dated 12/02/24, was reviewed, observations were made, and interviews with the resident and staff were conducted between 12/02/24 and 12/05/24. Resident 8's service plan was not reflective or did not provide clear direction to staff in the following areas:

* Alcohol-related behaviors, including resistance to care;
* Preference to sleep in her/his recliner chair; and
* Preference for front door to be open with a pet gate.

The need to ensure service plans were reflective of resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 08/2022 with diagnoses including chronic obstructive pulmonary disease and chronic pain.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 10/31/24, observation notes dated 09/02/24 through 11/24/24, and alert charting notes dated 09/03/24 through 12/02/24 were completed. Staff indicated the resident had recurrent issues with low oxygen levels and grogginess. The resident could make his/her needs known and direct his/her own care. Staff stated the resident frequently ran into things when groggier. The resident needed one staff assistance for ADL needs.

The resident’s service plan was not reflective, lacked resident-specific direction for staff, and/or was not consistently implemented by staff in the following areas:

* Falls and safety interventions;
* Evacuation assistance and process;
* Walker use and transfers for care;
* Smoking safety, tobacco use, marijuana use, and assistance needed;
* Oxygen use including liters required and resident compliance;
* Dressing, toileting, and incontinent assistance;
* Compression stockings;
* Chronic pain, prn medications, and non-drug interventions;
* Shower assistance and hospice services; and
* Edema, weight fluctuations, and intake.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Director/LPN) on 12/05/24. The staff acknowledged the findings.

3. Resident 2 was readmitted to the facility in 11/2024 with diagnoses including bipolar disorder and hallucinations.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 11/21/24, observation notes dated 09/03/24 through 12/02/24, and alert charting notes dated 09/02/24 through 12/02/24 were completed. Staff indicated the resident could direct his/her own care and make needs known. The resident had a fractured foot with a walking boot in place. The resident required one person assistance for ADLs and stand by assistance for transfers. The resident was more alert and clearer cognitively since his/her return from the hospital and medication changes made.

The resident’s service plan was not reflective, lacked resident-specific direction for staff, and/or was not consistently implemented by staff in the following areas:

* Suicidal statements;
* Walking boot use and fractured foot;
* Falls and safety interventions;
* Neck brace;
* Transfer assistance for toileting;
* Evacuation assistance and process;
* Auditory and visual hallucinations;
* Electric wheelchair care and use;
* Smoking safety, tobacco use, marijuana use, and assistance needed;
* Dressing, toileting, and incontinent assistance.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. The staff acknowledged the findings.

4. Resident 6 was admitted to the facility in 07/2020 with diagnoses including diabetes (Type 2), chronic obstructive pulmonary disease, and hypertension.

Review of clinical records revealed Resident 6’s service plan, dated 11/22/24, was not reflective of current resident status or did not provide clear direction for staff in the following areas:

* Destructive/abusive behaviors; and
* Use of psychotropic medications.

On 12/05/24 at 11:15 am, the need to ensure service plans were reflective of current resident status and care needs, and provided clear direction for staff was discussed with Staff 1 (Administrator) and Staff 3 (Wellness Director/LPN). They acknowledged the findings.

5. Resident 5 was admitted to the facility in 09/2023 with diagnoses including multiple sclerosis, myasthenia gravis, post-polio syndrome, and history of malnutrition.

The resident's 11/06/24 service plan and 09/03/24 through 12/02/24 temporary service plans were reviewed, interviews with staff and the resident were conducted, and observations were made. The resident's service plan was not reflective of needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas:

* Diet texture;
* Transfers;
* Suicidal ideation;
* Communication, including use of white board; and
* Confusion.

The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) at 2:05 pm on 12/05/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who experienced short-term changes of condition had resident-specific actions or interventions determined and documented, and residents' changes of condition were monitored consistent with evaluated needs, with progress noted at least weekly to resolution, for 2 of 6 sampled residents (#s 1 and 5) who experienced changes of condition. Resident 5 had ongoing weight loss which constituted a risk to the health, safety, and welfare of the resident. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 09/2023 with diagnoses including multiple sclerosis, myasthenia gravis, post-polio syndrome, and history of malnutrition.

The resident's service plan available to staff, dated 11/06/24, temporary service plans dated 09/03/24 through 12/02/24, 11/01/24 through 12/02/24 MARs, progress notes dated 09/03/24 through 12/02/24, and weight records dated 05/01/24 through 12/05/24 were reviewed, observations were made, and interviews with staff and the resident were conducted.

a. Review of Resident 5's weight records revealed the following:

* 05/01/24 – 134.6 pounds;
* 06/03/24 – 135.6 pounds;
* 07/2024 through 10/2024 – no record of weight documented;
* 11/06/24 – 115.4 pounds;
* 11/12/24 – 116.2 pounds; and
* 11/19/24 - 117 pounds.

Between 05/01/24 and 11/06/24 Resident 5 experienced a severe weight loss of 19.2 pounds, or 14% of his/her total body weight in 6 months. This constituted a severe weight loss and a significant change of condition. There was no documentation that the facility evaluated the resident, referred the weight loss to the facility nurse, documented the change, and updated the service plan.

The resident was weighed at survey request on 12/05/24 and weighed 111.6 pounds, an additional weight loss of 5.4 pounds since 11/19/24.

During the survey, 12/02/24 through 12/05/24, the resident was able to eat independently and was observed to consume 100 percent of his/her meals in either the dining room or his/her apartment. S /he ate three meals per day, confirmed by facility staff. Dining staff stated the resident at times had difficulty swallowing, so all food was cut up when s/he ate in his/her room but was left whole when able to be monitored in the dining room. Staff 10 (MT) and Staff 12 (MT) confirmed that the resident had trouble swallowing and all medications were administered crushed and in yogurt. The resident was not observed choking or coughing while survey observed meals.

During an interview at 11:15 am on 12/05/24, Staff 3 (Wellness Director/LPN) and Staff 4 (Wellness Coordinator/LPN) confirmed that there was no documentation that the resident was evaluated and referred to the RN for his/her weight loss or that the service plan was updated related to the weight loss.

The resident experienced a significant change of condition, severe weight loss. There was no documentation that the facility evaluated the resident, referred the weight loss to the facility nurse, documented the change, and updated the service plan. The resident continued to lose weight, which constituted a risk to the health, safety, and welfare of the resident.

b. The following short-term changes of condition, documented in the progress notes, lacked actions or interventions communicated to staff on all shifts and/or were not monitored at least weekly to resolution:

* 10/09/24 – New medication;
* 10/18/24 – Suicidal ideation;
* 11/08/24 – Unwitnessed fall;
* 11/17/24 – Missed medications and difficulty swallowing; and
* 11/23/24 – Unwitnessed fall.

The need to ensure all changes of condition had actions or interventions developed, implemented, communicated to staff on all shifts, and were monitored at least weekly to resolution was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3, and Staff 4 at 2:05 pm on 12/05/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 08/2022 with diagnoses including chronic obstructive pulmonary disease.

The resident's 10/31/24 service plan, 09/02/24 through 11/24/24 observation notes, alert charting notes, and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, lacked resident-specific directions to staff, and/or did not reflect evaluation of interventions for effectiveness in the following areas:

* Unresponsiveness/drowsiness related to medication use, low oxygen saturation levels, and marijuana/THC use;
* Power chair operation while drowsy with multiple crashes into objects; and
* Drowsiness/falling asleep while in the smoking area attempting to smoke.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution, provided clear, resident-specific directions to staff, and interventions were evaluated for effectiveness was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN) and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions, for 1 of 6 sampled residents (#5) who experienced significant changes of condition. The resident experienced ongoing weight loss which constituted a risk to the health, safety, and welfare of the resident. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 09/2023 with diagnoses including multiple sclerosis, myasthenia gravis, post-polio syndrome, and history of malnutrition.

Resident 5’s weight records revealed that between 05/01/24 and 11/06/24 s/he experienced a severe weight loss of 19.2 pounds, or 14% of his/her total body weight in 6 months. The resident was weighed at survey request on 12/05/24 and weighed 111.6 pounds, an additional weight loss of 5.4 pounds since 11/19/24. This constituted a severe weight loss and a significant change of condition.

There was no documented evidence an RN completed an assessment of the severe weight loss including findings, resident status, and interventions made as a result of the assessment and the resident continued to lose weight.

The need to ensure all significant changes of condition were assessed by an RN, with documented findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) at 2:05 pm on 12/05/24. They acknowledged the findings.

Refer to C270, example 1a.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and provided resident-specific parameters and staff instruction for 5 of 7 sampled residents (#s 2, 3, 5, 6, and 7) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 02/2012 with diagnoses including Type 2 diabetes.

Resident 7's 11/01/24 through 12/02/24 MARs were reviewed, and the following was identified:

The MAR directed staff to subcutaneously administer insulin glargine (long-acting insulin) bid and Humalog (fast-acting insulin) tid depending on the resident’s blood sugar and meal intake. The MARs revealed that staff documented the insulin doses but had not documented the location of the injections.

In an interview on 12/05/24 at 11:35 am with Staff 2 (Wellness Coordinator/RN) and Staff 3 (Wellness Director/LPN), it was confirmed that staff had not been documenting the sites of the insulin injections.

On 12/05/24, the need to ensure accurate documentation of the MAR was discussed with Staff 2 and Staff 3. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 02/2022 with diagnoses including Diabetes (Type 2), chronic obstructive pulmonary disease, and hypertension.

Review of Resident 6’s MAR, dated 11/01/24 through 12/02/24, identified the following:

a. The MAR lacked resident-specific parameters for use of the following PRN pain medications, and PRN bowel medications:

* The PRN medications for constipation were acetaminophen 650 mg supp, bisacodyl 10 mg supp, and Senna 8.6 mg tab. There were no instructions for the sequential order of administration of these medications; and

* The MAR listed two PRN pain medications. These were acetaminophen 325 mg tab (for pain or fever) and morphine sulfate 20 mg/ml sol (for pain or shortness of breath). The MAR lacked instructions for the sequential order of use of these medications.

b. Resident 6 was receiving subcutaneous insulin injections, with Humalog per sliding scale and routine Glargine. The MAR lacked documentation of injection sites for these administrations.

On 12/05/24 at 11:15 am, the need to keep an accurate MAR which provided resident-specific parameters and clear instructions for staff was discussed with Staff 1 (Administrator) and Staff 3 (Wellness Director/LPN). They acknowledged the findings.

3. Resident 5 was admitted to the facility in 09/2023 with diagnoses including multiple sclerosis, myasthenia gravis, post-polio syndrome, and history of malnutrition.

Review of the resident's 11/01/24 to 12/02/24 MARs and physician orders dated 11/06/24 to 12/02/24 revealed the following:

a. Two medications on 11/24/24 and three medications on 11/28/24 were not initialed as administered. There was no indication whether the medication had been administered.

b. PRN medications for shortness of breath lacked resident-specific parameters for administration:

* Albuterol HFA 90 mcg inhaler;
* Iprat Albuterol 0.5-2.5 mg/3 ml nebulizer; and
* Morphine sulfate 20 mg/ml solution.

The need to ensure the MAR was accurate and PRN medications contained resident-specific parameters and instructions for administration was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) at 2:05 pm on 12/05/24. They acknowledged the findings.

4. Resident 2 was readmitted to the facility in 11/2024 with diagnoses including chronic pain.

Review of the resident's 09/03/24 through 12/02/24 observation notes, physician communications, alert monitoring, and the 11/01/24 and 12/03/24 MARs/TARs showed the following:

* The resident had orders for MiraLAX, milk of magnesia, bisacodyl tablet orally, and a bisacodyl suppository.

All were ordered daily PRN for constipation. There were no resident-specific parameters for which medication to use first or when to start any of the medications.

The need to ensure PRN medications had resident-specific parameters for use was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. The staff acknowledged the findings.

5. Resident 3 was admitted to the facility in 08/2020 with diagnoses including dysphasia.

A review of the resident’s 11/01/24 through 12/02/24 MARs/TARs and physician orders identified inaccuracies in documentation.

There were a total of 21 blanks on the MARs/TARs for the following medications and treatments:

* Daily weights;
* Gabapentin (for neuropathy);
* Furosemide (for edema);
* Hyoscyamine (a gut antispasmodic);
* Compression socks (for edema); and
* Alert charting.

The resident had physician orders for four PRN pain medications. For two of these medications the physician noted the resident was “. . . able to self-direct . . .” Two of the PRN pain medication orders did not include resident-specific parameters regarding the order of administration or indicate the resident was able to self-direct administration.

The resident also had four PRN bowel care medications which lacked resident-specific parameters related to the order of administration.

The need for the MAR/TAR to be accurate was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24 at 2:34 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

During the re-licensure survey, 12/02/24 through 12/05/24, the facility’s posted staffing schedule and actual schedules for the period 11/17/24 through 11/30/24 were reviewed. On 10 of 14 overnight shifts, three staff were scheduled and worked.

The facility consisted of three floors of resident units. In an interview on 12/05/24 at 5:08 pm, Staff 3 (Wellness Director/LPN) and Staff 4 (Wellness Coordinator/LPN) identified multiple residents on the second and third floors of the facility who would need assistance down the stairs in the event of an emergency evacuation.

At the request of survey, the facility agreed to begin immediately scheduling five staff to work the overnight shift, starting on 12/05/24.

The need to have an adequate number of direct care staff available on the overnight shift to meet the 24-hour scheduled and unscheduled needs of the residents was discussed with Staff 1 (Administrator), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements that staff were providing to residents. Findings include, but are not limited to:

A review of the facility’s ABST revealed the care times and care elements documented for cares provided by staff were not accurate for Residents 1, 2, 4, and 6.

The need to ensure the ABST accurately captured care time and care elements was discussed with Staff 1 (Administrator), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an ABST evaluation was completed or updated for each resident before a resident moved in, whenever there was a significant change of condition, and/or no less than quarterly at the same time the resident’s service plan was updated for 3 of 8 sampled residents (#s 1, 2, and 5) and three unsampled residents. Findings include, but are not limited to:

The facility’s ABST was reviewed on 12/04/24. The following was identified:

*There was no documented evidence Resident 5 had been entered into the ABST when they moved into the facility; and
*Three unsampled residents’ ABST data had not been updated within the last 90 days.

The need to ensure all residents are entered into the ABST and reviewed as outlined in the rule was discussed with Staff 1 (Administrator), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 direct care staff (#s 11, 15, and 16) demonstrated satisfactory performance in assigned job duties within 30 days of hire and failed to provide documentation that medication technicians had been observed and evaluated as able to perform medication and treatment administration unsupervised prior to completing those tasks. Findings include, but are not limited to:

Staff training records were reviewed on 12/03/24 and the following was identified:

1. There was no documented evidence Staff 11 (MT), hired 02/12/24, Staff 15 (CG), hired 08/26/24, and Staff 16 (CG), hired 09/16/24, demonstrated satisfactory performance within 30 days of hire in the following areas:

* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation, and reporting changes of condition;
* Conditions that require assessment, treatment, observation, and reporting; and
* General food safety, serving, and sanitation.

2. There was no documented evidence that Staff 11 and Staff 16 demonstrated knowledge and performance in the areas of first aid and abdominal thrust within 30 days of hire.

3. There was no documented evidence, prior to survey entrance on 12/02/24, that staff had observed and evaluated Staff 11’s ability to perform safe medication and treatment administration unsupervised prior to performing the task.

During an interview on 12/03/24 at 2:00 pm, Staff 5 (Business Office Manager) stated the facility was not able to locate documentation of competency demonstrated for all MTs administering medications. She stated the competencies had been completed at some time in the past, but the facility was not able to find this documentation.

The lack of documentation was confirmed by Staff 1 (Administrator) at 2:45 pm on 12/03/24. As of 4:20 pm on 12/05/24, there was no documented evidence that 9 of 26 MTs scheduled to work in the week of 12/03/24 through 12/10/24 had demonstrated competency in administering medications. Staff 1 stated that Staff 3 (Wellness Director/LPN) and Staff 4 (Wellness Coordinator/LPN) were working with Staff 7 (RCC) and Staff 8 (RCC) to complete documentation with the MTs currently working and planned to make sure all others MTs demonstrated competency prior to administering medications.

The need to ensure the facility verified that direct care staff demonstrated satisfactory performance in any duty they were assigned within 30 days of hire was discussed with Staff 1, Staff 2 (Wellness Coordinator/RN), Staff 3, and Staff 4 at 2:05 pm on 12/05/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair and the facility grounds were kept orderly and free of litter and refuse. Findings include, but are not limited to:

The exterior grounds of the facility were toured on 12/02/24 at 11:15 am. The following areas were in need of cleaning or repair:

* The exterior pathways surrounding the building had multiple drop-offs measuring two to three inches, from the concrete surface to the ground. These drop-offs created a potential tripping hazard for residents; and

* There was a covered staff smoking area which contained large barrels for trash and recycling. The floor of this area was littered with trash and debris, including used gloves and cigarette butts.

On 12/03/24 at 12:35, the building's exterior was toured with Staff 6 (Environmental Services), and the areas of concern were reviewed.

On 12/04/24 at 3:35, the need to ensure all exterior pathways were maintained in good repair, and the grounds were kept orderly and free of litter and refuse was discussed with Staff 1 (Administrator) and Staff 6. They acknowledged the findings.

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

The interior of the building was toured on 12/02/24 at 11:15 am. The following areas were in need of repair:

* Scratches on wood cabinet fronts in dining room;
* Paint chips and damage to corners of walls in many areas;
* Scrapes and scuffs on baseboards in many areas;
* Gouges and damage to walls and pillars on second floor landing;
* Gaps and small holes in ceiling panels near second floor landing;
* Scrapes and damage to two tables in second floor puzzle room;
* Dark marks and scratches on doors and door jambs of rooms 118, 131, 135, 231, 240, and 241;
* Deep scrapes and gouges on door of first floor elevator; and
* Scratches and damage on paneling inside elevator.
* Carpet in rooms 315 and 318 showed heavy stains and damage.

On 12/03/24 at 12:35 pm the surveyor conducted a tour of the entire facility with Staff 6 (Environmental Services) and reviewed all areas needing repair.

On 12/04/24 at 3:35, the need to maintain all interior surfaces in good repair was discussed with Staff 1 (Administrator) and Staff 6. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure that residents could physically access their environment for 2 of 2 sampled residents (#s 1 and 2) and multiple non-sampled residents. Findings include, but are not limited to:

Residents 1 and 2, as well as several non-sampled residents, indicated they had difficulty physically accessing the resident courtyard due to the doors being locked and no assistive mechanism on the doors. The residents indicated they had to use their key to unlock the door to re-enter the building. Once they got the door unlocked, they then had to attempt to open/hold the door and maneuver their wheelchairs or walkers to get through the doors back into the building.

Observations of the courtyard area, dining room doors, and hall doors showed keys were required to re-enter the building from the outside through all the doors. Several residents struggled to get the doors unlocked, opened, and get themselves, their devices, and/or their personal items back indoors.

The need to ensure residents could physically access all resident use areas of the facility, regardless of mobility or devices in use, was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. The staff acknowledged the findings.

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

Observation of the kitchen on 08/26/24 at 11:00 am through 1:30 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 or underneath the following:

* Interior of ice machine;
* Flooring in corners, edges, between and under and behind equipment;
* Floor mat and flooring under mat by service line;
* Ceiling vents, light fixtures and sprinkler heads;
* Hood vents above grill/range;
* Industrial can opener and housing;
* Interior of ovens;
* Exterior and sides of grill;
* Interior/exterior of convection oven;
* Interior of microwave;
* Walls behind and beside grill/stove;
* Utility carts;
* Radio in prep area;
* Top shelf of steam line;
* Open stainless steal shelving;
* Metal racks in walk in cooler;
* Walls behind prep areas;
* Speed racks;
* Can rack holder;
* Multiple areas on walls throughout kitchen; and
* Reach in Deli cooler.

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

*Ice accumulation on door threshold and ceiling in walk in freezer;

c. Large oval serving trays, Large black service trays and grill spatulas observed heavily damaged with integrity concerns making them uncleanable surfaces.

d. Staff observed not performing hand washing when changing between dirty and clean dishwashing tasks. An additional staff member was observed to handle frozen raw beef products with gloves and then did not wash hands after removing gloves before beginning other tasks.

e. Deli reach in cooler did not have a thermometer to effectively monitor cold food storage temperatures. Upon entry to kitchen at 11:00 am, the walk-in cooler door was observed propped open as staff was putting away stock. The cooler thermometer read 50 degrees. The door continued to be propped open until 12:00 pm.

f. Multiple staff members preparing and/or serving food did not have hair/facial hair effectively restrained as required.

g. Facility was presetting service ware between meals with utensils exposed to potential contamination. Upon interview with dietary staff, they confirmed that after one meal service was completed, tables were cleared and dishes/utensils set for next meal. Dining room was not able to close and staff, residents, visitors and vendors had access to dining room between meals. Staff were unaware silverware needed to be covered.

h. Towels used for wiping/sanitizing found dirty and not stored appropriately in sanitizing solutions but random places around the kitchen.

i. Multiple food items were noted uncovered in the deli fridge area. No food items in deli fridge contained dates when prepared or use by dates. Multiple items in walk in cooler observed without open or use by dates.

j. Evidence of staff eating food in kitchen food prep area was found. Staff drinks were not of appropriate approved styles to ensure minimal potential contamination.

k. During meal service, multiple facility staff observed touching RTE (Ready to Eat) foods with ungloved/bare hands.

l. Facility using sponges for dishwashing. Multiple cleaning sponges were found heavily worn with evidence of pieces/chunks missing from them.

Surveyor toured and reviewed above areas with Staff 2 (Dining Services Manager) and they acknowledged the identified areas. At approximately 1:30 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Administrator) and they acknowledged the areas in need of correction.

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 observations and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and 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 kitchen on 11/05/2411:15am through 2:15pm and again on 11/06/24 from 11:15am through 12:15pm 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 or underneath the following:
* Interior of ice machine;
* Flooring in corners, edges, between and under and behind equipment;
* Kitchen drains;
* Shelving under tray line;
* Ceiling vents, light fixtures and sprinkler heads;
* Hood vents above grill/range;
* Industrial can opener and housing;
* Interior of conventional ovens;
* Exterior of all ovens;
* Interior/exterior of convection oven;
* Interior of microwave;
* Walls behind and beside grill/stove;
* Utility carts;
* Radio ;
* Top shelf of steam line;
* Open stainless steal shelving;
* Metal racks in walk in cooler;
* Walls behind prep areas;
* Speed racks;
* Trash cans:
* Windowsills;
* Interior of stainless steel drawers;
* Shelving storing clean dishes;
* Multiple areas on walls throughout kitchen; and
* Reach in Deli cooler.
b. Large oval and rectangular serving trays, Large black meal service trays continued with significant damage/integrity concerns making them uncleanable surfaces.
c. Deli reach in cooler did not have a thermometer to effectively monitor cold food storage temperatures.
d. Multiple staff members preparing and/or serving food did not have hair/facial hair effectively restrained as required.
e. Towels used for wiping/sanitizing found dirty and not stored appropriately in sanitizing solutions but random places around the kitchen.
f. Multiple items in walk in cooler observed without open or use by dates. Several items found not effectively covered/protected from potential contamination. Multiple items in cooler found past 7 days and should have been discarded.
g. Scoops were observed in bulk food items with handles touching food surfaces causing potential contamination.
h. Evidence of staff eating food in kitchen food prep area was found. Staff drinks were not of appropriate approved styles to ensure minimal potential contamination.
i. During meal service, multiple facility staff observed touching RTE (Ready to Eat) foods with ungloved/bare hands.
j. Food items were observed stored on the floor of walk in freezer and dry storage. Staff 2 (Dining Services Manager) validated stock was delivered the day before and should have been put away. Staff 2 acknowledge food should not be stored on the floor.
Cleaning lists were reviewed for November and no items were documented as being cleaned for November 1st thru the 5th. The surveyor asked for October’s cleaning lists which could not be located/provided. On 11/05/24 staff 1 (Administrator) was informed of the unsanitary condition of the kitchen and the concern that the facility’s plan of correction was not followed and progress on the areas previously cited had not occurred. Staff 1 was shown areas of concern and they acknowledged areas were not sanitary. Surveyor asked facility for an immediate plan to ensure resident safety. A plan was provided, which included immediate cleaning of the kitchen to began. Surveyor returned to facility on 11/06/24 at 11:15 am to validate improved sanitation. Facility staff provided evidence of kitchen staff training and kitchen areas above were noted with improvement. Staff 1 acknowledged continue implementation of the provided plan would continue to ensure ongoing compliance.

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.

Based on interview and record review, conducted during a site visit on 03/19/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (#1). Findings include, but not limited to:During an interview on 03/19/24, Staff 1 (ED) stated showers were documented on the shower sheets and the RCC reviewed the shower sheets weekly. S/He stated the resident would sign the shower sheets if they refused. Staff 1 stated housekeeping was done weekly and documented by the housekeepers.During an interview on 03/19/24, Resident 1 stated s/he was supposed to get standby assist for showers on Wednesday and Saturday mornings, but they had not been coming. S/He stated staff would come in at 9 pm and s/he would decline because it was too late. S/He also stated that s/he didn't get a shower for a month straight. Resident 1 stated they had a really good housekeeper, however, s/he only cames every other week.Review of Resident 1's service plan dated 02/19/24 indicated the resident required standby assistance with bathing twice weekly. There weren't any completed shower sheets for December 2023 and only one progress note dated 12/13/23 at 11 am which stated, "Asked resident if [s/he] would like to get ready for [his/her] shower per resident [s/he] received [his/hers] yesterday in the daytime".Review of December 2023 housekeeping logs indicated Resident 1 was getting weekly housekeeping done.The findings were reviewed with and acknowledged by Staff 1 on 03/19/24.It was confirmed the facility failed to ensure the implementation of services.Verbal POC: Facility will start weekly audits of the shower sheets by the RCC's and they will turn them into the nurse for review to ensure that residents are getting their showers and they are being documented.

Based on interview and record review, conducted during a site visit on 03/19/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#3). Findings include, but not limited to:A review of Resident 3's November 2023 MAR, progress notes, and physician orders indicated the following:· Order for Setraline 25 mg tab (Zoloft) to be given 0.5 tablet (12.5 mg) by mouth every day for depressive episodes.· November 2023 MAR revealed that between 11/26/23-11/30/23 resident did not get their medication due to it being out of stock and waiting on delivery from pharmacy.During an interview, Staff 1 (ED) and Staff 2 (Wellness Director) stated the incident had occurred. The findings were reviewed with and acknowledged by Staff 1 on 03/19/24.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: MT meeting last month on 2/14/24 to review policy and procedures for ordering/re-ordering medications and documentation.

The findings of the on-site investigation, conducted on 09/28/23, are documented in this report. The investigation 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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Based on interview and record review, conducted during a site visit on 09/22/23, it was confirmed the facility failed to develop and implement effective methods of responding to and resolving resident complaints. Findings include, but not limited to:The facility's grievance policy stated: "all grievances or complaints shall be documented on the Grievance Report form, including investigation results and efforts to address the issue." It also indicated the person filing the complaint would receive a report of the findings and resolution.Compliance Specialist reviewed the "Resident Grievance" log. The log contained six between March 20th, 2023-August 29th, 2023. The log did not include all investigation results and efforts to address the issues.In an interview on 09/28/23, Staff 1 (Wellness Director) stated the grievance binder was located at the front desk but was not used. S/he stated that residents will come to him/her or the ED with concerns at the front. The ED meets with the resident council, and they have town hall meetings monthly. S/he was unsure if the person filing the complaint received a report of the findings.In an interview on 09/28/23, Residents 3, 4, and 5 all stated there is no follow up to complaints. Resident 3 stated there was meetings once per month and the same concerns were brought up. Resident 4 stated they had asked for staff to come to his/her room to talk about his/her complaints and they did not come up.The findings were reviewed with and acknowledged by Staff 1 on 09/28/23.It was confirmed the facility failed to develop and implement effective methods of responding to and resolving resident complaints.Verbal plan of correction: Wellness director and ED will go over the grievance policy and there will be training at the stand-up meetings and next all staff on reporting, documenting, and following up on grievances.

Based on observation, interview, and record review, conducted during a site visit on 09/22/23, it was confirmed the facility failed to ensure the implementation of services for 2 of 2 sampled residents (#s 4 and 5). Findings include, but not limited to:On 09/28/23, compliance specialist (CS) observed the following in Resident 4 and Resident 5's apartment and bathrooms:· Dark rings and mold around the toilet bowl;· Trash full;· Debris on the floors (papers, crumbs, dust);· Dark rings around the sink and shower drains; and· Dirty dishes in the sink.In interviews on 09/28/23, Resident 4 and Resident 5 both stated they had not seen housekeeping in weeks, and they did not know what day they were supposed to come. Resident 4 stated s/he bought their own vacuum to clean with. Resident 5 stated staff had not been assisting him/her with weekly showers.In review of the housekeeping checklist for the week of 09/18/23 it was confirmed housekeeping had not cleaned Residents 4 and 5's rooms. On 09/28/23, CS reviewed the housekeeping log for the week of 09/23/23 and Residents 4 and 5 still had not received housekeeping. Resident 5's service plan, dated 08/30/23, indicated the resident required assistance with bathing weekly. The only completed shower sheets for Resident 5 for September 2023 were dated 09/24/23 and 09/09/23.The findings were reviewed with and acknowledged by Staff 1 on 09/28/23.It was confirmed the facility failed to ensure the implementation of services.Verbal plan of correction: Wellness director has implemented new task sheets that started this week (9/25/23), which includes showers and laundry for the residents. The RCC and staffing coordinator will be auditing weekly and will follow up with staff. There will be a Care Partner meeting on 10/4/23 to go over this process and documentation. HK schedule to be followed and ensure that weekly housekeeping is getting done if the HK is out.

Based on interview and record review, conducted during a site visit on 09/22/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#5). Findings include, but not limited to:Compliance Specialist reviewed Resident 5's May 2023 Medication Administration Record (MAR) and orders which indicated the following medications were not administered as ordered:" 05/04/23 Potassium Chl ER 20MEQ M-Tab " out of this medication. On order "" 05/07/23 Fluticasone 50m cg "bottle was empty, put on order"" 05/09/23 Fluticasone 50m cg "not delivered yet"" 05/11/23 Trelegy Ellipta 200-62.5-25m cg "med not in yet"" 05/11/23 Atorvastatin 10mg Tab "Med not here from pharmacy"" 05/15/23 Melatonin 3mg Tab "med not here"" 05/15/23 Allopurinol 100mg Tab "not in stock"" 05/15/23 Trelegy Ellipta 200-62.5-25m cg "not available"" 05/15/23 Cefdinir 300mg Cap "out of med"" 05/16/23 Cyanocobalamin 1000mcg/ml vial "product evaporated"" 05/17/23 Furosemide 20mg Tab "out of stock"" 05/18/23 Furosemide 20mg Tab "Satellite order from pharmacy, will give upon delivery"During an interview on 09/28/23, Resident 5 stated medications were not always ordered timely.The findings were reviewed with and acknowledged by Staff 1 on 09/28/23.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: There have been multiple MT meetings since May 2023. Re-training done on re-ordering meds, some MT were pulled and there has been new staff. RCC is doing more audits weekly.

The findings of the kitchen inspection, conducted 9/11/23, 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 re-visit to the kitchen inspection of 09/11/23, conducted 11/16/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview and record review, it was determined the facility failed to 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. Findings include, but are not limited to:Observation of the kitchen on 9/12/23 at 10:45 am through 2:00 pm revealed the following:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:* Interior of ice machine;* Flooring in door thresholds, corners, edges, between, under and behind equipment;* Floor mat by dish machine area;* Ceiling vents;* Hood vents above grill/range;* Fan cage, ceiling in walk in cooler;* Interior of reach in refrigerator/cooler;* Industrial can opener and housing;* Exterior and interior of range/ovens and grill;* Interior/exterior of convection oven;* Interior of microwave;* Industrial mixer;* Utility carts;* Radio in prep area;* Small appliances (blender/processor);* Interior of drawers by prep areas;* Wall behind and under warewasher; and* Multiple areas on walls throughout kitchen. b. The following areas were found in need of repair:* Caulking behind hand washing sink cracking with sections missing and or with black substance;* Caulking in ware washing area had large accumulation of black mold like substance;*Caulking behind all metal shelving/sink areas in need of replacement;* Ice machine water filter in need of replacement with visible over accumulation of contaminants;*Ice accumulation on door threshold and ceiling in walk in freezer;* Area in chemical/janitorial closet with pealing/chipped paint and small circular hole; and* Light fixture/bulbs in dry storage broken/out.c. Multiple cutting boards, one utility cart, and utensil handles were found damaged and in poor repair.d. Industrial, countertop mixer, and slicer found not covered when not in use.e. Facility not using pasteurized eggs for undercooked egg foods like poached, soft fried eggs. f. Multiple Staff member preparing and/or serving food did not have hair/facial hair effectively restrained as required. g. Scoops were found stored in bulk food item bins/containers.h. Towels used for wiping/sanitizing found dirty and not stored appropriately in sanitizing solutions but random places around the kitchen.i. Multiple ready to eat food items stored in kitchen area and in walk in cooler uncovered and exposed to potential contamination. j. Evidence of staff eating food in kitchen food prep area was found.k. During meal service, facility staff observed touching Ready to Eat (RTE) foods with potential contaminated gloves and placing RTE food products on visually soiled/dirty surface on tray line. Surveyor reviewed above areas with Staff 2 (Dining Services Manager) and s/he acknowledged the identified areas. At approximately 1:30 pm the surveyors reviewed the areas in need of cleaning, repair and practices with Staff 1 (Administrator). S/he acknowledged the areas.

Based on record review and interview, it was determined the facility failed to ensure 5 of 9 (#s 3, 4, 5, 6, and 7) sampled staff reviewed who prepared and served food had active food handlers certificates. Findings include but are not limited to:On 9/12/23 at approximately 1:15 pm, surveyor reviewed employee records for active food handlers cards. Staff 7 did not have a food handlers card on file and Staff #s 3, 4, 5, and 6 were found to be expired. At 1:30 pm, Staff 2 (Dining Services Director) verified there were multiple staff that did not have active food handlers certification. Staff 2 verified that those staff duties did include preparing food for residents.

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 11/29/2022. 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review, it was confirmed that the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include:Review of staffing schedules for November 2022, posted staffing plan, ABST, Resident #1 ' s service plan, and call light logs for 11/06/22-11/07/22. There were 9 call light response times for Resident #1 ranging from 20-42 minutes. The ABST reported 10.72 Staff needed on day shift and the posted staffing plan shows 8 Staff (3 med techs and 5 resident care partners). The November staffing schedules show less than 10 staff working on multiple days due to call outs. They are not staffing per the ABST, and the posted staffing plan does not reflect the ABST.The above information was shared with Staff #1 on 11/29/22, who acknowledged the findings.In an interview on 11/29/22, Staff #1 stated that they will normally only check the call light response times if there is a complaint. The facility expectation is that staff are responding to the call lights in less than 15 minutes.Plan of Correction: Facility will staff per the ABST and staffing plan. Retraining and reminders for staff at change of shift regarding call light response times. Regular auditing of the call light logs to ensure staff are responding timely.

Based on interview and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:Review of staffing schedules for November 2022, posted staffing plan, ABST, call light response times and service plan for Resident #1. Resident #1 had 9 call light response times on 11/06/-22-11/07/22 that were between 20-42 minutes. The ABST reported 10.72 Staff needed on day shift for 11/29/22 and the posted staffing plan shows 8 Staff (3 med techs and 5 resident care partners). The November staffing schedules show less than 10 staff working on multiple days during day shift due to call outs. They are not staffing per the ABST, and the posted staffing plan does not reflect the ABST. The facility census is 131 and only 122 residents are entered into the tool. Resident #1 has care needs that are not entered into the tool (including time spent responding to call lights).The above information was shared with Staff #1 on 11/29/22, who acknowledged the findings.In an interview on 11/29/22, Staff #1 stated that the facility is using the state ABST. The ABST is not currently updated with all the residents and their care needs. They have had some changes to their census. Resident #1 has had recent changes to their care needs which are not reflected on the ABST.

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 09/19/2022. 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and document review, it was confirmed that the facility failed to develop and implement a written policy that prohibits the falsification of records. Findings include:Compliance specialist (CS) reviewed Medication Administration Records (MAR) and progress notes for residents #1-2, policy and procedures regarding falsification of records, and Narcotic logs for July and August 2022. Resident #1 had a medication discontinued in July 2022 (which was not destroyed) and Staff #3 transferred Narc books and started a new entry for the medication. They documented 20 pills when there should have been 27.The above information was confirmed by Staff #1 on 09/19/22.In an interview on 09/19/22, Staff #1 stated that there need to be 2 staff members present to transfer narcotic books. Staff #3 was not following policy and procedures. This discrepancy was found when the logs were being audited for another resident ' s missed medications.Plan of correction:Full audit of medications and narcotic logs. Retraining for staff on med counts and accurate record keeping. More frequent oversight and auditing of the medication system.

Based on interview, observation, and record review, it was confirmed that the facility failed to prepare and serve food in accordance with the food sanitation rules. Findings include:Compliance Specialist (CS) observed the kitchen and dining room on 09/19/22. Observed lunch service and did not see any food that looked undercooked or spoiled being served. Food being prepared on clean surfaces. CS observed pictures emailed and pictures from residents ' camera with dates and times of food that was served in the facility. Observations include grapes with brown and yellow spots on them, chicken with a white film and a pink discoloration on them, beef with a very pink color to it, a baked potato with black spots, and beef stroganoff that does not look very appealing to the eye.CS reviewed food temp logs for 09/17/22-09/19/22 and did not find any discrepancies. Reviewed email dated 9/17/22 from Staff #2 addressing food concerns regarding the pictures received. Staff #2 will address each concern and ensure that employees are serving quality items and not sending out unsatisfactory food to the residents as well as provide additional training.The above information was shared with Staff #1-2, who acknowledged and agreed that some of the food items did not look appealing or edible.In interviews with Staff #1-2 on 09/19/22, they stated that they have recently received concerns regarding the food and were provided with emailed pictures of some of the food that was served. They have reminded staff not to serve food that doesn ' t look presentable. In an interview with Resident #1, they stated that food has been served raw, burnt, and spoiled. There is no follow up from the food meetings.Plan of correction:They will discuss food quality at tomorrows meeting, reminders to staff about not serving food that doesn ' t look presentable or isn ' t fresh, continue with the menu chat meetings, and recently switched produce providers.

Based on interview and record review, it was confirmed that the facility failed to ensure adequate professional oversight of the medication and treatment administration system. Findings include:In review of the facility ' s medication training policy and procedures, Resident #1-2s Medication Administration Records (MAR) and progress notes for August 2022, July and August narcotic logs, and Team member counseling notice dated 08/31/22. Staff #3 received written counseling for missing narcotics on 08/31/22. 2 Staff members were not signing of the med counts and Staff #3 started a new narc book alone, when 2 staff members are suppose to be present.In an interview on 09/19/22, Staff #1 stated that they did have some narcotics go missing. A resident reported that they did not receive a PRN narcotic that they requested, even though the staff member documented that it was given. The resident is an accurate reporter. Upon further review of the narc logs, it was found that another resident had a narcotic discontinued (which was not destroyed timely) and some of the medications were off on the count. Staff #3 was not following policy and procedures for narcotic counts, documentation of medication administration, or procedures for passing meds.Plan of correction:The staff member was suspended for internal investigation and then was let go. Police and APS were notified of the missing narcotics. There was a audit of the narc book, MT meeting this Friday, and staff are to immediately notify the nurse of any discontinued meds so they can be destroyed timely.