The Springs at Greer Gardens

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

1. Observation of the facility main kitchen occurred on 10/21/2025 from 10:15 am through 3:25 pm and the following was found:
a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on, in or underneath the following:

• Inside lower cabinets under sink and beverage dispensing machines in the soup and beverage station;
• Nozzle housing of juice dispensers;
• Ceiling vents in beverage/soup station; dish room; and vegetable prep/baking area;
• Ceiling fan in dishroom;
• Ceiling and walls near shake machine;
• Ice cream freezer;
• Microwave;
• Reach-in refrigerators found in beverage/soup station and service line area including undercounter refrigerator drawers;
• Black utility carts;
• Robotic delivery cart shelving;
• Range;
• Grill;
• Fryer;
• Reach-freezer next to fryer;
• Food warmers in cook/fry line;
• Hot plate warmer;
• Hood fire extinguisher or gas lines above range;
• Alto-Sham;
• Blast chiller;
• Rational combi-steamer;
• Kettle skillet;
• Sheet pan racks
• Plexi-glass in vegetable/baking prep area;
• Plastic lids on lower shelf in vegetable/baking prep area;
• Tray underneath cutting boards in vegetable/baking prep area;
• Wooden box attached to wall in vegetable/baking prep area;
• Drawers in vegetable/baking prep area;
• Insta-Pot;
• Vita-Mix;
• Immersion blender;
• Slicer;
• Weigh scale;
• Walls and grout around sink in dishroom;
• Sink disposer and power box in dishroom;
• Utility sink grout and mop bucket;
• Tops of cans and food storage bins in dry storage;
• Ice machine inside storage bin;
• Ice scoop holder;
• Floors in dishroom under scrap sink; dishwasher; and three sink unit;
• Floor in freezer;
• Floor drains in dishroom; in front of ice machine; and
• Garbage cans throughout the kitchen.

b. The following areas have been identified for needed repairs or replacement:
• Rusty rack in refrigerator located in beverage/soup station;
• Door seals on refrigerator number five in service line;
• Door gasket on Rational combi-steamer;
• White cutting boards on all food prep tables in main kitchen;
• Oven mitts and hot pads;

c. Handwashing sink next to small food prep table near range needs splashguard to avoid potential contamination of food and food contact surfaces.
d. Food contact surfaces of countertop mixers observed not covered or stored inverted to prevent potential contamination.
e. Multiple food items were found in kitchen cold and dry food storages open and exposed to potential contamination.
f. Kitchen staff observed to handle ready to eat items with potentially contaminated gloves used for other tasks.
g. Kitchen staff observed preparing food with excessive and dangling jewelry causing a potential for cross contamination.
Staff 1 (Food and Beverage Director) toured areas with surveyors and acknowledged areas of concern. At approximately 2:40 pm, surveyors reviewed above areas with Staff 2 (Memory Care Administrator), and Staff 4 (Executive Director) who acknowledged the identified areas.

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

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

This Rule is not met as evidenced by:

?Based on interview and record review, it was determined the facility failed to report incidents of abuse or suspected abuse to the local Seniors and People with Disabilities (SPD) office for 1 of 2 sampled residents (#2) who had incidents that were reviewed. Findings include, but are not limited to:
Resident 2 moved into the facility in 05/2021 with diagnoses including atrial fibrillation, congestive heart failure and stroke. The resident’s 12/18/24 to 03/17/25 progress notes and incident reports, 02/01/25 to 03/21/25 MARs, and current physician orders were reviewed. The following was identified:

The resident had orders for the following medications, all to be administered in the morning:

* Eliquis for atrial fibrillation (a heart condition);
* Flecainide for atrial fibrillation;
* Escitalopram for depression;
* Ferrous gluconate for anemia;
* Folic acid for supplement;
* Magnesium oxide for supplement;
* Vitamin C for supplement; and
* Calcium carbonate for supplement.

A 02/21/25 progress note stated, “[Day shift] MT went to check on Resident and to give [him/her] meds and…was found still laying in…bed and could barely speak…[Resident 2] was taken out to the Hospital.”

Review of the 02/21/25 MAR indicated Resident 2’s morning medications had been administered. However, a 02/21/25 incident report indicated the resident’s morning medications were found in the med cart. The incident report indicated the night shift MT had signed the MAR but did not administer the medications due to the resident still being asleep, and did not communicate to the day shift MT or correct the MAR.
The above incident constituted possible abuse/neglect, which required immediate reporting to the local SPD office. At 10:32 am on 03/18/25 Staff 1 (Health Services Administrator – AL) stated the incident had not been reported. Survey requested the facility report the incident, and confirmation was received at 1:21 pm on 03/18/25.

The need to ensure incidents of abuse or suspected abuse were immediately reported to the local SPD office was discussed with Staff 1, Staff 4 (Health Services Quality Coordinator) and Staff 5 (Regional Director of Operations) on 03/20/25. They acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action

(Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

This Rule is not met as evidenced by:
RV1 findings

Based on observation, interview, and record review, it was determined the facility failed to ensure a sufficient number of direct care staff to meet the fire safety evacuation standards, based on resident acuity and structural design, during the night shift. Findings include, but are not limited to:

a. During the acuity interview at 10:52 am on 03/17/25 the following was reported:

* The facility was a three-story ALF with a current census of 75 residents; and
* Five residents required a two-person assist to transfer, with four of them requiring a hoyer lift (three residing on the second floor and two residing on the first floor).

b. The facility reported on the Acuity-Based Staffing Tool (ABST) Facility Entrance Questionnaire the following:
* Two residents were identified as having support for behavioral symptoms; and
* Five residents were identified as having support for cognitive impairments.

c. The staffing plan posted by the facility was as follows:

* Day shift: 6:00 am to 2:30 pm: 4 CGs and 2 MTs;
* Swing Shift: 2:00 pm to 10:30 pm: 3 CGs and 2 MTs; and
* Overnight (NOC) Shift: 10:00 pm to 6:30 am: 2 CGs and 1 MT.

d. During an interview on 03/20/25, Staff 2 (ED) indicated facility procedure during an evacuation on the night shift was to call himself and Staff 1 (Health Services Administrator) to drive or walk to the facility to assist, as well as to use staff from the separately licensed MCC housed in the same building as part of the evacuation plan. He further stated the facility had purchased an “evacuation blanket” for emergencies. The blanket was in the ED’s office, and he stated the facility had not conducted drills using it for residents requiring two-person assistance for transfers.

e. Observations of the community, conducted from 03/17/25 to 03/20/25, revealed multiple sampled and unsampled residents used assistive devices (walkers and wheelchairs) for mobility.

The night shift staffing plan was insufficient to meet the fire evacuation standards of the Department for multiple sampled and unsampled residents based on their acuity and building structural design.

At 11:16 am on 03/20/25, the insufficient night shift staffing for evacuation standards was discussed with Staff 1 and Staff 2. An amended staffing plan to address the insufficient night shift staffing was requested and received by the survey team at 12:25 pm on 03/20/25.

The need to have a sufficient number of direct care staff to meet the fire evacuation standards was discussed on 03/20/25 at 1:02 pm with Staff 1, Staff 2, Staff 4 (Health Services Quality Coordinator) and Staff 5 (Regional Director of Operations). 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 interview and record review, it was determined the facility failed to ensure the posted staffing plan and Acuity-Based Staffing Tool (ABST) met the staffing requirements outlined in OAR 411-054-0070(1).

Refer to C 360.

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 interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and re-instruct, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire, and to keep a written record of the training, including the content and residents attending. Findings include, but are not limited to:

Documentation of fire and life safety training to residents was requested at 12:40 pm on 03/18/25. During an interview at the same time, Staff 2 (ED) stated the facility had been discussing fire and life safety topics during Resident Council Meetings but not instructing each resident within 24 hours of move-in and annually thereafter.

The need to ensure residents were instructed in fire and life safety within the specified timeframes, and to keep a written record of the training was discussed with Staff 1 (Health Services Administrator – AL), Staff 4 (Health Services Quality Coordinator) and Staff 5 (Regional Director of Operations) on 03/20/25. They acknowledged the findings, and no further information was provided.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. Findings include, but are not limited to:

The facility was a licensed ALF with three resident-occupied floors.

During the acuity interview at 10:52 am on 03/17/25, the resident census was identified at 75, with five residents requiring the assistance of two staff for transfers (three on the second floor and two on the first floor).

Review of six months of fire drill records indicated residents participated as follows:

* 09/27/24 – Four residents during day shift with a total evacuation time of 11 minutes, 20 seconds;
* 12/19/24 – Five residents during evening shift with a total evacuation time of 14 minutes; and
* 02/27/25 – No residents evacuated during night shift fire drill.

During an interview at 2:55 pm on 03/18/25, Staff 7 (MT) stated he had not practiced evacuating residents requiring two-person transfer assistance. During an interview at 1:34 pm on 03/18/25, Staff 6 (MT) stated she had not practiced evacuating residents requiring two-person transfer assistance.

Documentation of the facility’s emergency preparedness plan including evidence that a drill of the plan was conducted at least twice a year was requested at 9:30 am on 03/20/25 and was received at 9:36 am. There was no documented evidence the facility conducted a drill of the plan at least twice a year. Staff 2 (ED) confirmed at the same time that the facility was not conducting a drill of the plan at least twice a year.

The need to ensure the facility conducted a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required was discussed with Staff 1 (Health Services Administrator – AL), Staff 4 (Health Services Quality Coordinator) and Staff 5 (Regional Director of Operations) on 03/20/25. They acknowledged the findings, and no further information was provided.

OAR 411-054-0093 (1-5) Emergency and Disaster Planning

An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss.
(1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC.

(2) The emergency preparedness plan must:
(a) Include analysis and response to potential emergency hazards including but not limited to:
(A) Evacuation of a facility;
(B) Fire, smoke, bomb threat, or explosion;
(C) Prolonged power failure, water, or sewer loss;
(D) Structural damage;
(E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake;
(F) Chemical spill or leak; and
(G) Pandemic.
(b) Address the medical needs of the residents including:
(A) Access to medical records necessary to provide care and treatment; and
(B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation.
(c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff.

(3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested.

(4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills.

(5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request.

This Rule is not met as evidenced by:

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

Observation of the facility kitchen was reviewed on 10/08/24 from 10:30 am through 1:45pm and again on 10/09/24 from 10:45 through 1:30 pm and found the following:

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

* All reach in coolers and freezers;
* Sliding refrigerated drawers;
* Walk in freezer floor;
* Plastic and metal racks in walk in cooler;
* Wood shelving pieces in walk in cooler;
* Interior of ice machine;
* Kitchen drains;
* Floors under, behind and between equipment;
* Legs and wheels of large equipment;
* Interior and exterior of microwaves;
* Industrial can opener housing;
* Grill top and sides;
* Griddle top and sides;
* Interior of cabinet where clean plates were stored;
* Ceiling vents above food prep area;
* Vents above clean dish storage area;
* Floors throughout kitchen in corners and edges;
* Interior and exterior of hot box/warming containers;
* Interior of food transportation carts;
* Walls behind cooking areas;
* Walls where knives were stored;
* Mandolin;
* Interior of drawers;
* Sprinkler heads;
* Exterior and interior of stainless steel drawers;
* Under metal racks in dry storage;

b. The following areas were in need of repair:

*Multiple reach in coolers with damage to seals;
* Caulking in the dirty side of dish machine area with black debris build up.

c. Multiple food items found in walk in cooler and reach in coolers not covered and exposed to potential contamination.

d. Multiple prepared food items found past seven days. Multiple potentially hazardous food items not dated when opened and/or prepared. Multiple food items found past manufactures use by dates.
e. Multiple staff noted to be handling clean dishes and/or preparing food without facial hair restraints as required.

f. Line cook observed to serve cheeseburger patties to residents without checking proper cook to temperatures were met to ensure safety.

g. Multiple plastic spatulas for cooking were noted to have chips and other integrity concerns and in need of replacement.

h. Multiple hot mitts/potholders were noted to have holes and other integrity concerns and in need of replacement.

i. Staff drinks were observed stored in food preparation areas and did not contain lids/straws to minimize hand/lip contact as required.

On 10/08/24 at 11:15am and again on 10/09/24 at 1:00 Staff 1 (Assistant Executive Director) and Staff 2 (Food and Beverage director) were interviewed and acknowledged identified deficient areas/practices.
On 10/09/24 at 12:00pm Staff 3 (Executive Chef) was informed of areas in need of attention. They acknowledged identified areas.

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

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

This Rule is not met as evidenced by:

Based on record review and interview, it was determined the facility failed to ensure 7 of 16 staff (#3, 4, 5, 6, 7, 8, and 9) who prepared and served food had active food handlers certificates. Findings include, but are not limited to:

On 10/08/24 employee records were requested and reviewed to ensure staff had active food handlers certifications. There were six employees who's food cards could not be located and one staff (staff #4) who's card was expired. Staff 1 (Assistant Executive Director) indicated the facility had recently switched over to a new system and would attempt to retrieve copies of cards from corporate offices.

On 10/09/24 at 10:45am, Staff 1 provided a report provided from corporate offices validating that the additional six staff (cooks and Sous Chefs) had expired food handler cards. Staff 1 stated that the switch over of computer programs contributed to a lack of oversite on expired cards. The facility scheduled all expired staff to get their cards updated the following week. Staff 1, 2 and 3 acknowledged that all staff preparing food must have active food handlers cards and that seven of their staff's cards were not active.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service

(3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding:

(a) A review of their written position description with their job responsibilities.

(b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings.
(A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities.
(B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of
this rule.

(c) Abuse and reporting requirements.
(d) Fire safety and emergency procedures.

(e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease.

(A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:
(i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease.
(ii) Policy addressing respiratory hygiene and coughing etiquette.
(iii) Standard precautions.
(iv) Hand hygiene.
(v) Use of personal protective equipment.
(vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection.
(vii) Isolating and cohorting of residents during a disease outbreak.
(viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks
under ORS 433.004 and safeguards for employees who report disease outbreaks.

(B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.
(i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.
(ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.

(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below:
(A) Effective March 31, 2024, all staff must have completed the required training.
(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities.
(g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate.

(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.
(a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.
(A) Documentation of dementia training:
(i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training.
Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.
(ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.
(B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training.
(C) A certificate of completion must be made available to the Department upon request.
(D) Pre-service dementia care training must include the following subject areas:
(i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.
(ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.
(iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.
(iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:
(I) Identify and address pain.
(II) Provide food and fluids.
(III) Prevent wandering and elopement.
(IV) Use a person-centered approach.

(b) ORIENTATION TO RESIDENT. Pre-service orientation to resident:
(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan.
(B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

This Rule is not met as evidenced by:

Based on interview and record review, conducted during a site visit on 02/13/24, it was confirmed the facility failed to ensure that staff visually observe the resident take the medication for 1 of 1 sampled resident (# 7). Findings include, but not limited to:Resident 7's medication error report dated 01/22/23, January 2023 Medication Administration Record (MAR), and January 2023 progress notes, indicated that on 01/22/23, the night shift MT had documented medications were administered without visually observing the resident take his/her scheduled 8:00 pm and 9:00 pm medications. The medications were found the next morning in a cup in another resident's room.During an interview, Staff 2 (Resident Services Coordinator) stated the med techs had to visually observe the residents take the medication before leaving the room. S/he stated staff were not supposed to be pre-popping medications.The findings were reviewed with and acknowledged by Staff 1 (ED) and Staff 2 on 02/13/24.It was confirmed the facility failed to ensure that staff visually observe the resident take the medication.Verbal plan of correction: Medication error was reported to Adults and People with Disabilities. The MT responsible was counseled by the RN.

Based on interview and record review, conducted during a site visit on 02/13/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 6). Findings include, but are not limited to:Resident 6's physicians orders, dated 01/26/24, indicated Resident 6 was to receive Carvedilol 6.25mg tab: 1 tablet by mouth twice daily with meals. Hold for HR less than 60, SBP less than 100 for hypertension. Resident 6's January 2024 Medication Administration Record (MAR), and January 2024 progress notes, indicated that on 01/26/24 and 01/29/24-01/31/24, Resident 6 was not administered his/her morning dose of Carvedilol 6.25mg tab.During an interview on 02/13/24, Staff 2 (Resident Services Coordinator) stated during an audit report missed medications were reviewed on the MAR and checked against the med cart. It was found that the medications were not given, and the vitals were not taken or documented. The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 02/13/24.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: Med techs were made aware of the error. Personal one on one training was done for all med techs involved. Management to work on night shift with staff for additional training. Staff 2 had begun weekly audits of missed meds, meds not available, and refusals.Based on interview and record review, conducted during a site visit on 02/13/24, 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 are not limited to:Resident 5's medication error report, dated 06/12/23, June 2023 Medication Administration Record (MAR), and June 2023 progress notes, indicated that on 06/12/23, s/he was given another resident's medications in error. The medications given were Primidone 100mg, Lisinopril 40mg, and Lacosamide 150mg, which were not prescribed for the resident. During an interview, Staff 2 (Resident Services Coordinator) stated the night shift MT had two cups with medications in them and gave Resident 5 a cup with the wrong room number on it. S/he also stated staff were not supposed to be pre-popping medications.The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 02/13/24.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: Personal one-on-one training was done for the med tech involved, including additional training with the lead med tech. Management to work on night shift with staff for additional training. Staff 2 had begun weekly audits of missed meds, meds not available, and refusals.

Based on interview and record review, conducted during a site visit on 02/13/24, it was confirmed the facility failed to conduct a thorough assessment before the use of supportive devices with restraining qualities for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:Resident 4's MAR, dated 05/24/23, indicated s/he had a bed rail that was placed to the right side of his/her bed.A review of a side rail/bed cane assessment for Resident 4, indicated the facility began the assessment on 05/25/23 but did not complete or sign the assessment until 07/14/23. An incident report, dated 07/08/23, indicated Resident 4 had fallen and had been wedged between the bed and bed rail on 07/07/23.During an interview on 02/13/24, Staff 2 (Resident Services Coordinator) confirmed the incident on 07/08/23 did occur. S/he stated the initial bed rail assessment was started by a nurse that no longer worked at the facility, however, it was not completed before the bed rail was installed.The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 02/13/24.It was confirmed the facility failed to conduct a thorough assessment before the use of supportive devices with restraining qualities.Verbal plan of correction: Administrator will ensure that all assessments are done before restraining devices are put into place moving forward.

Based on interview and record review, conducted during a site visit on 02/13/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to:A review of the facility's ABST and resident roster on 02/13/24 indicated the following:- There were 76 residents listed on the roster and 73 residents entered into the ABST;- Resident 1 had a service plan update on 01/01/24 and their ABST was last updated on 10/17/23;- Resident 2 had an update to their service plan on 01/02/24 and their ABST was last updated on 09/27/23; and- Resident 3 had a service plan update on 02/11/24 and the ABST was last updated on 09/28/23.In an interview on 02/13/24, Staff 1 (Executive Director) stated the current census was 74 residents. S/he also stated there had been new move-ins, move-outs, and service plan updates, however, the ABST was not updated since the last administrator was working.On 02/13/24, findings were reviewed with and acknowledged by Staff 1.It was determined the facility failed to fully implement and update an ABST.

The findings of the kitchen inspection, conducted 07/25/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 07/25/23, conducted 10/11/23, 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 second revisit, to the kitchen inspection of 07/25/23, conducted 12/20/23, 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 and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen, reviewed on 07/25/23 from 10:45 am through 2:50 pm, revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Waffle maker;* Reach in coolers and freezers;* Walk in freezer floor;* Plastic and metal racks in walk in cooler;* Cooling fans and cages in walk in and ceiling with dust accumulation;* Bottom two plastic shelves storing potatoes;* Interior of ice machine;* Interior and exterior of microwave;* Industrial can opener; and * Box fan and oscillating fan blades and cages. b. The following areas were in need of repair: * Metal racks in reach in coolers with rust and peeling paint; and * Caulking behind hand washing sink with black mold like substance.c. Commercial slicer was not covered when not in use. Staff 3 (Executive Chef) verified slicer did not have a cover. d. Multiple cutting boards and cutting surfaces were found heavily stained and scored.e. Prepared salads were observed stored in coolers without covers and open to potential contamination. A tray of salads was sitting on top of tray cart for memory care delivery. Two trays of dessert items were observed in walk in freezer uncovered. Staff 2 (Food and Beverage Director) stated everything should be covered before placing in coolers to protect from potential contamination. f. Multiple food packages were found open in dry storage. Pipes and vents in dry storage had heavy dust accumulation posing potential contamination risk to open packages.g. Multiple bulk food bins or packages were found with scoops stored inside/on food product exposing it to potential contamination.h. Multiple dishwashing racks were observed stored on the floor. i. Multiple kitchen staff observed during tray line service to use single service gloves incorrectly. Multiple occasions ready to eat items were handled with gloves that had been used for other tasks including touching handles of ovens, fryer baskets, and cooler handles. Gloves were not removed after touching face, hair, glasses or clothing then observed to make sandwiches and/or handle fresh basil, garlic bread and shredded parmesan. At approximately 2:00 pm, the surveyor reviewed above areas with Staff 2 (Food and Beverage Director) and Staff 3 (Executive Chef), who acknowledged the identified areas. At 2:45 pm, the areas were reviewed with Staff 1 (Executive Director) and he acknowledged the concerns.
Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:Observation of the facility kitchen, reviewed on 10/11/23 from 11:15 am am through 1:00 pm, revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Walk in freezer floor; and* Cooling fans and cages in walk in and ceiling with dust accumulation.b. The following areas were in need of repair: * Metal racks in reach in coolers with rust and peeling paint. c. Multiple kitchen staff observed during tray line service to use single service gloves incorrectly. Multiple occasions ready to eat items were handled with gloves that had been used for other tasks including touching handles of ovens, fryer baskets, and cooler handles. Staff were also observed to handle raw meat products with gloves and did not wash hands before donning clean cloves. Staff were observed to handle ready to eat food products with bare hands.d. Staff were observed to prepare multiple beef burgers and a veggie patty on the grill and did not check temperature prior to serving to residents. Staff 3 (Executive Chef) acknowledged the expectation for line cooks to check the temperature of potentially hazardous food items prior to service to ensure they had been cooked to the appropriate temperature as required. At approximately 1:00 pm, the surveyor reviewed above areas with Staff 2 (Food and Beverage Director) and Staff 3 (Executive Chef), who acknowledged the identified areas. At 12:45 pm, the areas were reviewed with Staff 1 (Administrator) and s/he acknowledged the concerns.

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

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 04/14/2023. 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

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 04/14/2023. 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

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 04/14/2023. 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

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 04/14/2023. 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

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 04/14/2023. 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

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 04/14/2023. 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

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 04/14/2023. 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

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 04/14/2023. 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

The findings of the re-licensure survey, conducted 9/13/21 through 9/15/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 09/15/21, conducted 01/31/22 through 02/01/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the relicensure survey, conducted 9/13/21 through 9/15/21, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.Refer to deficiencies in report.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:During a tour of the environment on 9/14/21, a propane gas fire pit measuring 29 inches square by 29 inches high was observed in the common outdoor area adjacent to the dining room. It was not in use at the time of the observation. On 9/15/21 at 10:30 am, the finding was reviewed with Staff 1 (Executive Director) who turned the fire pit on by an unsecured knob and ignition switch on the outside of the structure. There was no barrier that prevented access to the flame which posed a significant safety risk to the residents. At 12:30 PM on 9/15/21, Staff 1 reported the knob which turned on the gas had been removed. At 1:50 PM, Staff 18 (Director of Operations) reported the gas shut-off valve to the fire pit would be capped the following day. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1, Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 6 sampled residents (#2) was treated with dignity and respect. Findings include, but are not limited to: During the acuity interview on 9/13/21, it was reported that Resident 2 had been temporarily relocated to another apartment secondary to the need to complete maintenance in his/her permanent residence. In an interview on 9/14/21 with Staff 9 (CG), she reported that Resident 2 used his/her call light on 9/13/21 to request to use the bedside commode for a bowel movement. Staff 9 reported she told the resident the bedside commode was unavailable and instructed him/her have his/her bowel movement in their incontinent garment. This constituted a failure to treat the resident with dignity and respect. The failure of the facility to ensure residents were treated with dignity and respect was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident incidents were thoroughly investigated in a timely manner and/or reported to the local Seniors and People with Disability (SPD) office for 2 of 3 sampled residents (#s 2 and 5) who were reviewed with injuries. Findings include, but are not limited to:1. Resident 5 admitted to the facility in August of 2017 with diagnoses to include neuralgia (nerve pain) and curvature of the cervical spine.The service plan and Staff interviews revealed Resident 5 required two persons with bed mobility and transfers, using a mechanical lift device since admit to the facility.Review of Resident 5's record revealed s/he was sent to the hospital for uncontrolled pain on 5/15/21.During an interview on 9/14/21 at 9:15 am, Resident 5 reported the cause of the increased back pain was related to two staff that moved him/her up in bed by pulling up under both of his/her arms. The resident reported feeling severe back pain during the bed mobility assistance provided. On 9/14/21 Staff 6 (Resident Services Coordinator) reported he was unaware of an incident causing Resident 5's back pain. Staff 6 then completed an interview with the resident and confirmed the resident's report.The surveyor asked Staff 2 (Health Services Administrator) to report the incident to the local SPD office. Confirmation of the self report to the local SPD office was received on 9/14/21.The need to ensure resident incidents were thoroughly investigated and reported to the local SPD office was discussed with Staff 1 (Executive Director), Staff 2, Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.
2. Resident 2 was admitted to the facility in February 2018. Resident 2's 6/13/21 through 9/13/21 facility record was reviewed.* On 8/3/21, a hospice bath aide note stated, "Looks as if (s/he) has a scratch on right hip."* On 8/23/21, a hospice bath aide note stated, "Looks like (s/he) has a skinned left knee."There was no documented evidence the facility was aware of the injuries, had investigated the injuries to rule out abuse or reported them as injuries of unknown cause to the local SPD office. The facility was directed to report the injuries of unknown cause on 9/14/21. A fax confirmation of the report was provided prior to exit that day. The need to ensure injuries of unknown cause were investigated to rule out abuse and reported to the local SPD office unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

2. Resident 5 was re-admitted to the facility in July 2021. The following required elements were not addressed or included on the move-in evaluation form:* Personality, including how the person copes with change or challenging situations; * Complex medication regimen;* Recent losses; * Unsuccessful prior placements; and* Environmental factors that impact the resident's behavior including but not limited to noise, lighting and room temperature. On 9/15/21, the need to ensure the move-in evaluation contained all required elements was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure the new move in evaluation contained all required elements for 2 of 3 sampled residents (#s 3 and 5) whose new move-in evaluations were reviewed. Findings include, but are not limited to:Review of Resident 3's new move-in evaluation, dated 6/23/21, lacked the following elements:* History of mental health treatment;* Effective non-drug interventions;* Personality and how the person copes with change and challenging situations; and* List of treatments.The need to ensure all required components were included in the new move-in evaluation was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 5 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

5. Observations, interviews and review of Resident 5's service plan dated 6/22/21 revealed it was not reflective of the resident's current status and lacked clear instruction to staff in the following areas:* Activity assistance;* Non-drug interventions for back pain;* Meal set-up in bed, including specific positioning of food;* Clothing protector for meals;* Straw in all drinks;* Two person full assist for bed baths;* Two person assist for dressing;* Grooming assistance instruction;* Hygiene assistance instruction;* Back brace prior to transfers out of bed, including clear instructions (7/21/21);* Clear instructions for two person bed mobility assist to minimize discomfort;* Air mattress on bed; * Dependent on mobility in wheel chair; * Evacuation assist;* Home Health PT and OT;* Continence of bowel and bladder with instructions; * Limited range of motion to upper extremities;* Bed bound; * Range of motion to lower extremities instructions; * Bilateral half side rails on bed; and * Ability to make needs known and direct cares. The need to ensure all resident service plans were reflective and provided instructions to staff was discussed on 9/15/21 with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator). The staff acknowledged the findings.
3. Review of Resident 2's 6/21/21 service plan, interviews with staff and observations of the resident revealed the service plan was not reflective of the resident's care needs and did not provide clear direction to staff in the following areas: * Hospice; * Hospice bath aide provision of bathing services;* When to call hospice;* Pre-medication for pain prior to providing assistance with ADLs and transfers;* Two-person assistance with dressing, toileting/brief change and bed mobility;* Right hip pain with bed mobility, lower extremity dressing and brief changes;* Continence;* Limited upper extremity range of motion; * Assistance for grooming;* Presence of dentures;* Hospital bed;* Bedside commode; and* Evacuation assistance. The need to ensure the service plan was reflective of the resident's care needs and provided clear direction to staff was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.
4. Resident 3 was admitted to the facility in 7/2021 with a diagnosis of Parkinson's disease.During an interview on 9/13/21 Staff 7 (Resident Services Coordinator) identified Resident 3 to be independent for all ADL care. She also confirmed Resident 3's service plan was not updated within 30 days of his/her move-in date.Observations of Resident 3 on 9/14/21 at 9:30 am revealed s/he asked for assistance to get out of his chair.Review of Resident 3's progress notes dated 7/16/21 through 9/12/21 revealed s/he used a CPAP machine. An interview with Staff 13 (MT) at 12:25 pm on 9/14/21 revealed Resident 3's service plan did not reflect his/her current care needs in the following areas: * Transfer assistance;* Use of CPAP;* Ability to eat using utensils;* Ability to understand and be understood;* Use of wheel chair;* Alert and oriented to time and place; and* Housekeeping services.Interview with Staff #7 (Resident Services Coordinator) on 9/13/21 confirmed Resident 3's service plan was not updated within 30 days of move in. The need to ensure service plans were reflective of care needs, provided clear direction to staff, and were updated within 30 days was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 on 9/15/21. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status, provided clear direction to staff, were updated within 30 days of admission and quarterly and were followed for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in September 2020 with diagnoses including Dementia.During the acuity interview on 9/13/21, Resident 1 was identified to have edema, weight loss and was in a relationship with another resident. Observations, interviews, and review of the current service plan dated 9/7/21, revealed the service plan was not reflective of the resident's current status or provided clear instructions to staff, in the following areas: * Edema and significant weight changes; and * Relationship status with another resident. The need to ensure Resident 1's service plan was reflective of the resident's current status and provided clear instructions to staff was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.2. Resident 4 was admitted to the facility in October 2020 with diagnoses including Type 1 Diabetes.Observations of the resident, interviews with staff, and a review of the resident's 5/6/21 service plan indicated the service plan failed to reflect the resident's current care needs and lacked clear directions to staff in the following areas:* Skin wound and treatment plan; and* Home health wound care services and recommendations.The need to ensure resident service plans were reflective of the resident's current status and provided clear directions to staff was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

4. Resident 4 was admitted to the facility in October 2020 with diagnoses including Type 1 Diabetes.Review of the resident's 6/23/21 through 8/18/21 outside provider notes identified changes of condition related to a leg wound.There was no documented evidence the facility RN monitored the status of the leg wound or coordinated with the outside agency providing wound care to ensure their monitoring instructions and interventions were implemented and documented in the resident's record. Interviews with staff during the survey from 9/13/21 through 9/15/21 confirmed the facility failed to monitor and document on the status of the wound. The need to ensure the facility monitored the resident and documented on the progress of the wound at least weekly following a change of condition was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 ( Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.
2. Resident 6 was admitted to the facility in November 2017 with diagnoses including chronic obstructive pulmonary disease.Resident 2's progress notes dated 6/25/21 through 9/13/21 were reviewed and revealed the resident experienced the following changes of condition:* On 6/25/21, progress notes revealed a fall with a head wound; and * On 8/15/21, progress notes revealed a fall with multiple rib fractures.There was no documented evidence the head wound had been monitored weekly to resolution.The facility failed to implement the determined intervention to lower Resident 6's bed related to the fall on 6/25/21.There was no documented evidence Resident 6's fall interventions were evaluated with each instance and monitored for effectiveness.The need to ensure the facility had a system for evaluating changes of condition and monitoring until resolved was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings. 3. Resident 5 admitted to the facility in August of 2017 with diagnoses to include neuralgia, neuritis and kyphosis of the cervical region.Review of Resident 5's record revealed s/he was sent to the hospital for uncontrolled pain on 5/15/21.During an interview on 9/14/21 at 9:15 am, Resident 5 reported the cause of the increased back pain was related to two staff moving him/her up in bed by pulling under both of his/her arms. The resident reported feeling severe back pain as a result from the assistance provided. The resident experienced a change of condition related to increased pain resulting in transfer to the hospital. There was no evaluation completed to determine potential cause, determine actions/interventions indicated. The need to ensure the facility had a system for evaluating changes of condition was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.
5. Resident 2 was admitted to the facility in February 2018 with diagnoses including failure to thrive. a. Review of Resident 2's 3/20/21 through 9/14/21 weight records revealed the resident experienced the following significant weight changes: * Resident 2's documented weight went from 122.8 pounds on 4/5/21 to 105 pounds on 6/26/21, which was a 17.8 pound or 14.49% weight loss in two months which constituted a severe weight loss and significant change of condition. There was no documented evidence the facility evaluated the resident, referred to the facility RN and updated the service plan. * Resident 2's documented weight went from 105 pounds on 8/24/21 to 120 pounds on 9/9/21, which was a 15 pound or 14.28% weight gain and constituted a severe weight gain and significant change of condition. There was no documented evidence the facility evaluated the resident, referred the resident to the facility nurse or updated the service plan . The facility was requested to reweigh the resident during survey. Resident 2's weight on 9/14/21 was 120 pounds. b. Review of Resident 2's 6/13/21 through 9/13/21 facility record revealed the resident experienced multiple short-term changes of condition related to the following for which the facility failed to determine what actions and interventions were needed for the resident, communicate them to staff on all shifts, update the service plan and monitor the changes until resolution: * TIA;* UTI;* Medication changes;* Stage 1 pressure area on right hip;* "Skinned" left knee; and* Scratch on right hip. The failure of the facility to evaluate the resident, refer to the facility RN and update the service plan when the resident experienced significant changes related to weight and failure to determine what actions and interventions were needed for the resident when they experienced short term changes of condition, communicate them to staff on all shifts, update the service plan and monitor the changes through resolution was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to evaluate and monitor changes of conditions, refer any significant changes of condition to the RN, determine and document actions or interventions and communicate those to staff for 5 of 6 sampled residents (#s 2, 3, 4, 5, and 6) who had changes of condition. Findings include, but are not limited to:1. Review of Resident 3's progress notes and nursing notes dated 7/16/21 through 9/12/21 revealed s/he was not monitored after being admitted to the facility in 7/2021.Physician orders dated 8/27/21 revealed Resident 3 had multiple medication changes and s/he was not monitored for effectiveness or adverse side effects for the following medication changes:* Solifenacin succinate;* Trazadone;* Pramipexole;* Triamcinolone cream;* Trihexyphenidyl 1 mg; and* Trihexyphnidyl 2 mg.Interviews with Staff 7 (Resident Services Coordinator) and Staff 1 (Executive Director) on 9/14/21 confirmed staff had not monitored Resident 3 after s/he moved into the facility or when medications were changed.The need to ensure the facility evaluate and monitor changes of conditions, refer any significant changes of condition to the RN, determine and document actions or interventions and communicate those to staff was discussed with Staff 1, Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 on 9/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for significant changes of condition, including findings, resident status and interventions made as a result of the assessment, for 2 of 4 sampled residents (#s 2 and 6) who experienced significant changes of condition related to significant weight changes and a fall with fractures. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 2017 with diagnoses including chronic obstructive pulmonary disease.During the acuity interview on 9/13/21 it was revealed that Resident 6 had fallen and sustained multiple rib fractures. Resident 6 experienced a significant change of condition related to the fall with multiple rib fractures. There was no documented evidence an RN assessment was completed for the significant change of condition. The need to complete an RN assessment for significant changes of condition, to include findings, resident status and interventions, was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator) Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator). They acknowledged the findings.
2. Resident 2 was admitted to the facility in February 2018 with diagnoses including failure to thrive. Review of Resident 2's 3/20/21 through 9/14/21 weight records revealed the resident experienced the following significant weight changes: a. Resident 2's documented weight went from 122.8 pounds on 4/5/21 to 105 pounds on 6/26/21, which was a 17.8 pound or 14.49% weight loss in two months which constituted a severe weight loss and significant change of condition. There was no documented evidence the facility RN completed an assessment following the resident's significant weight loss. b. Resident 2's documented weight went from 105 pounds on 8/24/21 to 120 pounds on 9/9/21, which was a 15 pound or 14.28% weight gain in one month and constituted a severe weight gain and significant change of condition. There was no documented evidence the facility RN completed an assessment following the resident's significant weight gain. The need to ensure the facility RN completed an assessment when resident's experienced significant changes of conation was discussed with Staff 2 (Health Services Director), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 7) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:During the acuity interview on 9/13/21, Resident 7 was identified to be administered insulin injections by non-licensed staff. Review of Resident 7's delegation documentation during the survey revealed the following:Staff 14 (MA) was initially delegated to perform insulin injections on Resident 7 on 7/7/21. Re-evaluation of Staff 14's delegation duties was not completed within 60 days of initial delegation.The need to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

2. Resident 5's records were reviewed and identified he/she was receiving home health physical and occupational therapy services. The facility failed to ensure the following home health recommendations made between 7/16/21 and 8/30/21 were added to the service plan and communicated to staff:* "Check heels, elbows, bottom frequently"; * "Donn back brace in bed by rolling prior to hoyer transfer";* "Once in tilt in space wheel chair, tilt pt (patient) all the way back";* "Please have staff assist pt into wheelchair one time per day each day";* "Bed to wheelchair hoyer lift, please get pt into wheelchair one time per day two person assist for rolling and mobility"; and* "Please get pt up in wheelchair that she has in room currently. Pt tolerates being in wheelchair for 30-60 minutes at a time".During interview with Staff 2 (Health Services Administrator), he reported that the resident refuses to get up to the wheelchair.There was no evidence the facility had communicated the residents refusal to get up from bed with staff to the outside provider, nor was the service plan updated and recommendations communicated to staff.The need to ensure outside provider care was coordinated and implemented was reviewed with Staff 1 (Executive Director), Staff 2 ( Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator). They acknowledged Resident 5's service plan had not been updated to include the home health recommendations.
Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure that clinical information was reviewed and recommendations added to the service plan for 3 of 4 sampled residents (#s 2, 4 and 5) who were receiving services from outside providers. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in February 2018 with diagnoses including failure to thrive. During the acuity interview on 9/13/21, the resident was reported to receive hospice services from an outside service provider.Review of Resident 2's 6/13/21 through 9/13/21 facility record revealed the following hospice communications and clinical information were not reviewed for follow up and were not added to the service plan: * 6/25/21: RN: "Call hospice prior to administering ...lorazepam";* 6/28/21 RN: "Fluids bedside";* 7/5/21 RN: "Calendar to monitor BM";* 8/3/21 Bath aide: "Looks as if (s/he) has a scratch on R hip";* 8/3/21 RN: "Premedicate with morphine prior to cares"; * 8/9/21 RN: "1. Monitor for signs and symptoms of UTI 2. Track BMs ...5. Continue to medicate patient prior to cares/transfers with morphine."* 8/23/21 Bath aide: "Looks like (s/he) has a skinned left knee."* 9/1/21 RN: "Please, please, please have staff utilize BM tracking calendar in (his/her) bathroom. There was only one BM tracked for August and I'm guessing that's not accurate in regards to frequency. I need the information for documentation and to be sure (s/he) is comfortable."The failure of the facility to coordinate care with outside providers, ensure that clinical information was reviewed and recommendations added to the service plan was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.
3. Resident 4 was admitted to the facility in October 2020 with diagnoses including Type 1 Diabetes. During the acuity interview on 9/13/21, Resident 4 was identified as receiving outside provider services related to wound care.Outside provider notes for the previous 90 days were requested. Three HH notes were provided and reviewed: * HH note dated 6/23/21 identified the wound was worsening and instructed staff to monitor the wound for saturation daily and change as needed; * HH note dated 7/23/21 indicated the resident received wound care from HH once a week; and * HH note dated 8/18/21 instructed staff to encourage the resident to elevate their lower extremity and for staff to monitor signs and symptoms of an infection and to report concerns to HH 24/7. Interviews on 9/14/21 and 9/15/21 revealed staff were unclear on how often HH provided wound care or if the resident was going out to a wound clinic. There was no documented evidence the facility consistently collected written information from the outside provider visits or implemented the above instructions and monitoring into the resident's record. The need to ensure ongoing coordination of care was maintained, documented, and implemented was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator), and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication system and adequate professional oversight. Findings include, but are not limited to:During the relicensure survey, conducted 9/13/21 through 9/15/21, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas:* C 282: Systems: RN Delegation and Teaching;* C 302: Systems: Tracking Controlled Substances;* C 303: Systems: Medication and Treatment Orders;* C 305: Systems: Residents Right to Refuse;* C 310: Systems: Medication Administration;* C 325: Systems: Self Administration of Medication; and* C 330: Systems: Psychotropic Medications.Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 9/15/21.

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 3 sampled resident (# 2) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:Resident 2 was admitted to the facility in February 2018 with diagnoses including a history of a lumbar compression fracture. Resident 2's 6/23/21 signed physician orders included .25 ml morphine sulfate oral solution prn every 2 hours for severe pain or shortness of breath. Review of the 8/1/21 through 9/13/21 MAR and Controlled Substance Disposition logs revealed one dose of morphine sulfate was signed out on the disposition log on 8/14/21 and another on 9/4/21. Neither were initialed as administered on the MAR. The need to ensure an accurate narcotic disposition log was maintained for all controlled substances was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

2. Review of Resident 2's current physician orders and 8/1/21 through 9/12/21 MAR revealed the following: a. The facility lacked documented evidence of signed provider orders for the following medications that were transcribed onto the MAR: * Antac + sim (stomach upset);* Milk of Magnesia (bowel care);* Sodium Phosphate enema ( bowel care); * Triple antibiotic ointment (skin); and * Sulfa/trim antibiotic (UTI). b. Signed prescriber order dated 6/25/21 indicated staff were to call hospice RN prior to administering lorazepam for anxiety/agitation/shortness of breath. Resident 2 was administered lorazepam on 8/19/21. There was no documented evidence the facility called the hospice RN prior to the administration of the medication. The need to ensure signed prescriber orders were documented in the resident's facility record for all medications the facility was responsible to administer and that orders were carried out as prescribed was discussed with Staff 2 (Administrator), Staff 6 (Resident Service Coordinator) and Staff 7 (Resident Service Coordinator) on 9/15/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for all medications the facility was responsible to administer, for 2 of 6 sampled residents (#s 2 and 3) whose MARs and orders were reviewed. Findings include, but are not limited to:1. Review of Resident 3's MAR dated 9/1/21 through 9/12/21 and most recent signed physician's orders dated 8/27/21 revealed the following medication which were not on the MAR:* Atorvastin 20 mg (cholesterol);* Hydrocortisone acetate1% cream (itch); and* PRN Trazadone 50 mg (sleep).The need to ensure medication and treatment orders were carried out as prescribed for all medications the facility was responsible to administer was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

2. Resident 2 was admitted to the facility in February 2018 with diagnoses including compression fracture of lumbar vertebrae and constipation. Review of Resident 2's current signed physician orders and 8/1/21 through 9/13/21 MAR revealed the resident had refused to consent to multiple medication orders in the time frame reviewed: * Polyethylene Glycol (bowel care) 11 times;* Acetaminophen (pain) twice;* Ibuprofen (pain) twice; and* Senna (bowel care) twice.During an interview with Staff 7 (Resident Services Coordinator) on 9/15/21, she reported they had not notified the physician of the refusals. The need to ensure the physician was notified when a resident refuses to consent to a medication or treatment order was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator and ) and Staff 7 on 9/15/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 1 and 2) who had documented medication refusals. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in September 2020.Physician orders directed staff to notify the physician if the resident refused medications for three consecutive days. Resident 1's MAR from 9/1/21 through 9/13/21 was reviewed and revealed the following: * The resident refused all his/her medications consecutively from 9/1/21 through 9/4/21 and 9/8/21 through 9/12/21. There was no documented evidence the facility notified the physician when the resident refused medications for three consecutive days.The need to ensure the facility notified physicians or practitioners of medication refusals was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, provided clear instruction and parameters for administration of PRN medications, were accurately transcribed, included reason for use, effectiveness of PRN medications administered and listed potential side effects for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 5's 9/1/21 through 9/13/21 MARS were reviewed and revealed the following:* PRN pain medications (Tylenol, Oxycodone and Tramadol) lacked clear instruction to staff regarding the order of administration; * PRN Senna lacked clear instructions for administration in relation to multiple other PRN bowel care medications;* PRN Tramadol was initialed as administered on 9/1/21 and 9/13/21. There was no evidence the medication had been signed out on the narcotic log or removed from the bottle; and* The MAR did not include the reason for use for Diazepam.The need to ensure MARs were accurate, included reason for use and clear parameters and instruction to staff for medication administration was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings. 2. Resident 6's 9/1/21 through 9/13/21 MARS were reviewed and revealed the following:* Multiple PRN bowel care medications (Glycerin Suppository, Milk of Magnesia, Miralax and Senna) lacked instruction to staff regarding the order of administration; and* The MAR did not include the reason for use of Spireva Respirmat inhaler and Caltrate+D3.The need to ensure MARs included reason for use, clear parameters and instruction to staff for medication administration was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.
3. Review of Resident 2's 8/1/21 through 9/13/21 MAR and current physician orders revealed the following: * Instructions on the MAR for prn acetaminophen were to administer for mild pain and morphine for moderate to severe pain. There were no parameters listed for staff to determine what constituted mild/moderate/severe pain. * Prescriber orders on 8/3/21 instructed staff to call hospice RN prior to administration of Lorazepam. The instructions were not transcribed onto the MAR. * Reasons for use for scheduled acetaminophen and ibuprofen were incorrectly transcribed onto the MAR from the physician's order.* Senna was indicated to have been held on 9/3/21 without documentation as to the reason. * PRN morphine instructions on the MAR indicated the medication was to be administered for moderate to severe pain or shortness of breath. The medication was administered multiple times during the time frame reviewed without documentation as to the reason for administration. The need to ensure MARs were accurate, included clear parameters and instruction to staff for medication administration was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.
4. Review of Resident 3's MAR dated 9/1/21 through 9/12/21 was reviewed and revealed the following medications lacked reasons for use:* Donepezil;* Finasteride;* Florastor;* Lions mane mushroom tab;* Reservatrol;* Liposomal Glutathione liquid;* Lisinopril;* Pramipexole;* Rosuvastin;* Solifenacin Succinate;* Trazadone;* Vitamin B-12;* Xarelto;* Pramipoxele;* Trihexyphenidyl HCL;* Loperamide; * Geri-Lanta Susp; and* Multiple bowel medications (bisacodyl suppository, milk of mag and sodium phosphate enema).The need to ensure all medications have a reason for use was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 5 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.
5. Resident 1 was admitted to the facility in September 2020 with diagnoses that included Major Depressive Disorder and Atrial Fibrillation.Resident 1's 9/1/21 through 9/13/21 MAR was reviewed and identified the following medications were lacking reasons for use: * Bystolic;* Sertraline;* Flecainide; and* Trimethoprim.The need to ensure MARs were accurate and included reasons for use was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings. 6. Resident 4's 9/1/21 through 9/13/21 MAR was reviewed and identified the following:* PRN Polyethylene Glycol Powder lacked clear instructions for administration in relation to multiple other PRN bowel care medications.The need to ensure MARs included clear instructions to staff for medication administration was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure self-administration of medication evaluations were completed quarterly for 1 of 4 sampled resident (#4) who self-administered medications. Findings include, but are not limited to:Resident 4 was admitted to the facility in October 2020 with diagnoses including Type 1 Diabetes.During the acuity interview on 9/13/21, Resident 4 was identified as self-administering his/her insulin injections.A review of the clinical record revealed the self-administration evaluation was last completed on 10/26/20. There was no documented evidence the facility had completed the quarterly self-administration evaluations for Resident 4's insulin injections.The need to ensure the facility evaluated Resident 4's ability to safely self-administer his/her insulin injections quarterly was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure prn medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychotropic medication for 1 of 1 sampled resident (#2) whose facility record was reviewed for psychotropic medications. Findings include, but are not limited to:Resident 2 was admitted to the facility in February 2018. Review of Resident 2's facility record revealed signed physician orders dated 6/23/21 which included: Lorazepam, 0.5 mg, to be administered prn every four hours for anxiety/agitation/shortness of breath. Review of the the 8/1/21 through 9/14/21 MAR revealed it lacked instruction related to non-pharmalogical interventions for staff to attempt prior to administration of the medication and failed to identify how the resident's anxiety/agitation was displayed.Resident 2 was administered prn Lorazepam on 8/19/21. There was no documentation which indicated why the medication had been administered or that non-pharmalogical interventions had been attempted prior to administration. The need to ensure non-pharmalogical interventions were listed on the MAR for staff to attempt prior to administering psychotropic medications for behaviors and that the interventions were attempted with ineffective results prior to administration of the medication was discussed with Staff 2 (Health Services Administrator), Staff 6 (Resident Service Coordinator) and Staff 7 (Resident Service Coordinator) on 9/15/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure supportive devices with potentially restraining qualities were assessed, included a thorough review by an RN, PT or OT prior to use, documented less restrictive alternatives prior to use, and provided instruction to caregivers on the correct use of and precautions for the device for 1 of 2 sampled residents (#5) who had side rails on their bed. Findings include, but are not limited to:On 9/14/21 Resident 5's bed was observed to have two quarter length side rails in the up position. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT including documentation of less restrictive alternatives prior to use, nor was there evidence the service plan had identified the use of and precautions related to the device.The lack of assessment and instructions provided for use of supportive devices with potentially restraining qualities was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Health Services Coordinator) and Staff 7 (Health Services Coordinator) on 9/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 11 and 14) had documentation of demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:Review of training records with Staff 3 (Business Office Manager) on 9/15/21 revealed Staff 11 (CG) and Staff 14 (MT) lacked documented evidence competency was demonstrated in the following required areas: * The role of service plans in providing individualized care; and* Providing assistance with ADLs;The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was reviewed with Staff 3 (Business Office Manager), Staff 2 (Health Services Administrator), Staff 6 (Resident Service Coordinator) and Staff 7 (Resident Service Coordinator) on 9/15/21. No further information was provided.

Based on interview and record review, it was determined the facility failed to document a minimum of 12 hours of annual in-service training related to the provision of care in a community based care was completed for 1 of 3 long term staff (#17) whose training records were reviewed. Findings include, but are not limited to:Staff training records reviewed on 9/15/21 revealed Staff 17 (CG), hired 9/1/17, had completed six of the required 12 hours of annual in-service training.The need to ensure all required in-service training hours and requirements were completed annually was reviewed with Staff 3 (Business Office Manager), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. No further information was provided.

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components and fire life safety training was conducted on alternating months. Findings include, but are not limited to:Fire and life safety records for March 2021- August 2021 were reviewed and lacked the following components:* Location of simulated fire origin;* Evacuation time period needed;* Escape route used; * Number of occupants evacuated; and* There was no documented evidence that fire and life safety training was conducted on alternating months of fire drills.The need to ensure the facility was in compliance with all required fire drill components and fire and life safety instruction was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator), Staff 6 (Resident Services Coordinator) and Staff 7 (Resident Services Coordinator) on 9/15/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure perimeter walkway surfaces were maintained in good repair. Findings include, but are not limited to:Observations of the concrete walkways along the perimeter of the building on 9/14/21 showed there were multiple drop offs of 2-6 inches along pathway edges which created potential hazards for residents. The need to ensure the pathways did not have potential safety hazards was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Administrator) on 9/15/2121. The staff acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:During a tour of the environment on 9/15/21 with Staff 2 (Health Services Director), the fireplace in the common area across from the mailboxes was turned on for inspection. The temperature of the metal screen covering the fireplace registered 147 degrees F when measured with the surveyor's thermometer. Staff 2 reported he would keep the remote control for the unit in his office until the fireplace screen reached a temperature below 120 degrees. The need to ensure residents could not come into incidental contact with fireplace elements that exceeded 120 degrees F was discussed with Staff 2 on 9/15/21. He acknowledged the findings.