Brookdale Geary Street

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals.

Based on observation and interview, it was determined the licensee failed to ensure adequate administrative oversight of facility operations regarding kitchen sanitation practices, which posed a risk to the safety of residents. Findings include, but are not limited to: During the annual kitchen inspection, conducted 11/17/25 through 11/20/25, administrative oversight to ensure adequate food sanitation practices in the facility kitchen was found to be ineffective based on the severity of the citation. 1. A situation was identified where there was a failure of the facility to comply with the Department’s rules that was likely to cause residents serious harm. An immediate plan of correction was requested on 11/17/25 at 12:00 pm in the following areas: OAR 411-054-0030 Resident Services, Meals, Food Sanitation Rule. The facility provided a plan of correction on 11/17/25 at 2:24 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system(s) failure(s) associated with the licensing violation. 2. Refer to C240.

Beginning the week of December 22nd, the administrator will complete a food sanitation and safety audit using Brookdale tool every other week. The audits will continue for the next 60 days. Audit results will be maintained in a binder in the administrator's office. New kitchen cleaning task sheets were presented and implemented during kitchen staff meeting. Documentation of the completion of cleaning tasks will be kept in a binder in the kitchen. Dining Services Manager will review the kitchen for compliance with community cleaning tasks 5 days a week. The Manager on Duty will complete this review on the DSM's days off. For the next sixty days, Brookdale Traveling Pro-Tem will provide oversight and training for kitchen staff including Dining Services Manager. The Executive Director and DSM will meet weekly with Pro-Tem and/or District Director of Operations to review kitchen cleaning and sanitation audit results.

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals.

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).

Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. The facility’s kitchen was observed in an unsanitary condition, with a person in charge without adequate knowledge or training, with multiple failed food safety practices which posed an immediate jeopardy situation that could threaten the health, safety, and/or welfare of residents. Findings include, but are not limited to: Observations of the facility kitchen and lunch meal service were completed on 11/17/25 from 10:10 am through 2:30 pm, and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black matter was visible on or underneath the following: * Floors in the dining room; * Multiple chairs in the dining room; * Kitchen entrance threshold floor; * Stainless steel prep tables; * Stainless steel open shelving; * Interior and exterior of ice machine; * Ice machine scoop holder; * Juice machine area by nozzles; * Top of beverage dispensers; * Utility carts; * Hand washing sink; * Stainless steel shelving above hand washing sink; * Legs of prep tables; * Walls and floors throughout kitchen; * All kitchen drains; * Shelving under the steam table; * Interior and exterior of cabinets storing clean dishes; * Steam table wells; * Faucet and handles of prep sink; * Interior and exterior of temperature regulated/insulated carts; * Walk-in cooler floors under metal shelving and in thresholds; * Walk-in cooler metal racks; * Walls in walk-in cooler; * Interior of plastic bin storing fruit and vegetables; * Removable metal racks in walk-in cooler; * Fan cages of walk-in cooler and freezer; * Celling and sprinkler head in walk-in cooler; * Interior and exterior of microwave, convection ovens, and industrial steamer; * Removable hood vents; * Piping/electrical conduit by oven and wall; * Stove top burner plates; * Knobs and handles of stove and grill; * Industrial can opener and housing; * Industrial mixer; * Stainless steel table where mixer was located; * Interiors and exteriors of stainless steel drawers throughout kitchen; * Outsides, lids and handles of trash cans; * Windowsills and screens; * Vents and light fixtures; * White food bin exteriors; * Floors in dry storage; * Oven mitts; * Interior of clear plastic bin storing clean cooking utensils; * Knife holder attached to knives (knives and holder); * Sanitizer dispenser; and * Sides of steam line cabinets. b. The following areas were in need of repair: * A section of wall by the entry to the kitchen threshold was damaged near floor. * Caulking behind the three-compartment sink had black matter build-up and was in need of replacement. * Multiple areas in tile floor had missing grout; c. Scoops and spoons were observed in bulk food containers with handles touching food surfaces. d. Multiple kitchen staff were observed preparing food and/or handling clean dishes without appropriate facial hair restraints as required. Staff 2 (Dining Services Director) had visibly soiled and very dirty outer clothing. Staff 2 was observed to wipe his hands on his outer clothing multiple times during the review. e. Staff 2 was interviewed regarding how often sanitizer buckets were changed and he indicated every four hours, not every two hours or as needed per rule. f. The handwashing sink did not have paper towels to properly dry hands. Facility staff were not able to state when the dispenser had run out of towels. The hand washing sink also had visible debris inside the sink indicating was used for purposes other than hand washing. g. Multiple kitchen staff, including Staff 2, were not observed washing hands as required. This included times where hands were contaminated from touching clothing, other surfaces, and/or handles. h. Multiple food items were observed stored in dry storage, walk-in cooler and/or freezer that were not closed or covered and were exposed to potential contamination. i. A large container of used/dirty/rancid oil was observed stored uncovered under a shelf in the back food prep area. The facility did not have a system to correctly dispose of used cooking oil. Staff 2 indicated that bucket had been there for at least 2-3 months. j. A trash can without a liner and with visible food debris was observed stored in the dry food storage area. k. Staff 2 was preparing a ground beef product for lunch. The product was placed into the steam well without checking the temperature to ensure it had reached 155 degrees F for 15 seconds. Surveyors intervened and asked Staff 2 to check the temperature. It was found ranging between 140-145 degrees F. Staff 2 indicated they often put the products in about 10 degrees under to finish cooking in the steam wells. Surveyors indicated food for service must be fully cooked prior to placement in the steam wells and that food should not be “cooked” in the steam tables. Staff 2 also was not aware that ground beef could not be served at a medium doneness and must be fully cooked (155 degrees F or higher). l. Staff 2 was observed to check food temperatures with a thermometer that was not at a fully cooked temperature and did not sanitize thermometer prior to checking temperatures of fully cooked product, potentially contaminating the fully cooked product. Staff 2 was not observed to sanitize thermometer before, between products, or after use before storing probe in protective cover. m. Multiple kitchen towels were observed stored in various places throughout the kitchen, not in the sanitizer buckets as required. Several were visibly soiled and stiff. Staff 2 was observed to wipe his hands with a kitchen towel without observation of appropriate hand hygiene measures. n. Boxes of food product were observed stored on the floor of the walk-in freezer. In an interview, Staff 2 confirmed the facility had received stock more than 24 hours prior. o. Multiple cutting boards were found heavily scored or stained and in need of replacement. Multiple oven/hot mitts were found damaged with holes and rips. p. Lunch place settings including utensils were set at time of entry to facility. Lunch meal service was at noon. Utensils were observed uncovered and open to potential contamination. q. Staff 2 was not able to demonstrate knowledge in cleaning practices, effective hygiene practices, effective sanitation practices, correct cooking practices, proper cooling practices, appropriate cold and dry food storage practice, or proper reheating processes. In an interview on 11/17/25 at approximately 12:00 pm, Staff 1 (Executive Director) and Staff 3 (Associate Executive Director) was informed by the Surveyors of the significant sanitation and safety concerns, and that the kitchen would be shut down. The facility was instructed to submit an immediate plan of correction to address the unsanitary and unsafe conditions. Staff 1 had toured the kitchen area with the surveyors and had observed and acknowledged the areas identified and in need of immediate attention/correction. An immediate plan of correction to address the deficient kitchen sanitation practices was requested on 11/17/25 at 12:00 pm. The facility provided a plan of correction on 11/17/25 at 2:24 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system(s) failure(s) associated with the licensing violation. On 11/20/25 at 10:15 am, the surveyors returned to inspect progress of addressing sanitation and poor repair concerns. Surveyors toured areas with Staff 4 (District Director of Operations), Staff 5 (Traveling Dining Services Specialist). Staff 4 and Staff 1 outlined the ongoing training plan for the Person-In Charge and the ongoing oversight of the food service operations. The facility also outlined the plan for a consultation from a Registered Dietitian at least quarterly for an extended amount of time to ensure on going compliance. Facility acknowledged lack of adequate staff for kitchen was a contributing factor to poor sanitation. At that time, it was determined the facility could safely resume food service operations.

Areas of the kitchen and dining room including but not limited to: Floors in the dinning room, chairs, kitchen enterance threshold, prep tables, shelving, ice machine, ice machine scoop holder, juice machine nozzles, beverage dispensers, utility carts, hand waskhing sink, prep tables, walls and floors, drains, steam table, cabnets that store clean dishes, steam table wells, facet hands, insultated cars, walking in cooler racks, walls of walk in cooler, food starage bins, fan cages, ceiling and sprinkeler in walk-in colloer, hood vents, stovetop burner plates, knobs and handles of stove and grill, industrial can opener, industrail mixer/stand, stainless steel drawers throughout the the kitchen windowsills and screens, floors in dry storage, oven mitts, knife holder and sanitizer dispenser. Have been cleaned and will continue to be maintained in good, clean working order. The section of the wall by the entery of the kitchen threshold will be repaired and replaced with a cleanable surface. Caulking behind three-compartment sink has been replaced. Scoops will be stored in designated holder, not in food product. Beard nets have been ordered and are availible to staff with facial hair. Aprons are availible to staff and will be changed when soiled. Hand hygiene training will be completed by all kitchen staff. Sanitizer buckets will be changed every two hours or as needed. Checking/changing paper towels for hand washing sink will be completed on task sheet daily. food items will be closed and/or covered to prevent potential contamination. Oil container has been removed and routine oil disposal oil disposal will be completed. Trash cans will not be stored in dry storage area. Training on reaching proper food temperature completed for all kitchen staff members. New theromometers ordered with disposable covers. Training on the use of these completed for all kitchen staff. All spills will be cleaned and towels will be removed from the floor promptly. Food product will not be stored on the floor. Cutting boards will be replaced. Utensils will be rolled in napkins prior to setting tables. A Registered Dietition will provide quarterly audits and partnership to ensure continued compliance. Staff training on policies and procedures of kitchen operations completed with staff. Weekly audits to be completed by administrator. Documentation of this will be kept in a binder in the kitchen. New task sheets for cleaning tasks presented during all staff meeting. Documentation of this will be kept in a binder in the kitchen. Weekly meetings to review kitchen status with Pro-temp and/or District Director of operations.

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).

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement program that evaluated services, resident outcomes and resident satisfaction. Findings included, but are not limited to: During the annual kitchen survey, conducted 12/24/24, quality improvement oversight was found to be inadequate to ensure the facility's dining services were maintained in a safe and sanitary condition, following Oregon food code practices and menus as outlined in rule.

Weekly audits to be completed by administrator. Documentation of this will be kept in a binder in the kitchen. New task sheets for cleaning tasks presented during all staff meeting. Documentation of this will be kept in a binder in the kitchen. DSC will complete cleaning audits 5 days a week. Menu chat will held twice monthly where concerns will be addressed. Comment cards and grievance log will be reviewed five times weekly by ED and followed up on in a timely manner.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

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).

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 completed on 12/27/24 from 10:30 am through 2:30 pm and the following was identified: 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: * Floors throughout kitchen; * Floors in the dining room; * Walk in cooler floors under metal shelving and in thresholds; * Walls throughout kitchen behind prep areas; * Open shelving throughout kitchen; * Interior and exterior of microwave; * Interior and exterior of convection ovens; * Industrial can opener and housing; * Industrial mixer; * Door thresholds with food debris/splatter; * Interiors and exteriors of stainless steal drawers; * Go racks stored in walk in; * Metal racks in walk in cooler and freezer; * Outsides and handles of trash cans; * Small appliances (blender/robot coupe); * Windowsills and screens; * Vents and light fixtures; * White food bin exteriors; * Utility carts; * Dish washing rack dolly/cart; * Interior and exterior of food transportation carts; * Clean area of dish washing station; * Floors and walls in dish washing area; * Kitchen drains; and * Water cooler in dining room; b. The following areas were in need of repair: * Multiple ceramic tiles in threshold of walk in cooler and freezer with cracks; * Multiple areas in dining room walls with missing, chipped or scrapped paint; * The walk in freezer had a large accumulation of ice that was on cardboard boxes and had dripped/froze potentially contaminating food product in the cardboard boxes below the drip/freeze. c. Scoops/spoons observed in bulk food containers with handles touching food surfaces. d. Multiple potentially hazardous foods were found past 7 days from the original preparation date. A large container of chicken salad was dated 11/16/24 and was observed to have visible mold growth on the food product. Another container of tuna salad was dated 11/22/24 and was observed with visible signs of food decay/rot. A container of prepared sandwiches was noted dated 12/14/24, 14 days from preparation date. e. Multiple food items found in walk in cooler noted without proper labels and/or dates when opened or prepared as required. Multiple items were found open and/or not covered/sealed appropriately to protect from potential contamination. f. Multiple kitchen staff were observed preparing food and/or handling clean dishes without appropriate facial hair restraints as required. g. A kitchen employee was observed to have on plastic gloves underneath visibly heavily soiled rubber gloves washing dishes. The staff removed the soiled gloves and handled clean dishes with the visible wet plastic gloves on underneath the soiled rubber gloves. No hand hygiene step was observed between dirty and clean tasks as required. h. A container of hot sauce, a visible dirty metal baking supply, and a to-go coffee cup was observed on the clean side of the dish machine potentially contaminating the clean area of the dish area. The coffee cup was an employee drink and did not contain the appropriate straw or handle as required. i. The kitchen had four red surface sanitizing buckets. These buckets were tested for appropriate surface sanitizing levels. The facility was asked for test strip and a quat 10 strip provided. None of the four buckets registered any concentration of sanitizing solution. Staff 2 (Dining Services Coordinator) was asked to make a fresh bucket and test the solution. The chemical that came from the dispenser did not register any quat sanitation which is what staff 2 thought was the sanitizing chemical. When asked how frequent the buckets were changed staff 2 responded every 3-4 hrs not the every 2 hrs or as needed per rule. Facility indicated they would contact their Eco lab representative to check the dispenser as soon as possible. j. The snack fridge on the unit did not contain a thermometer to ensure food was stored at the appropriate cold food storage temperature. k. A week’s worth of menus was requested at the start of survey, Staff 2 indicated the facility did not currently have 7 days of menus in advance as required. Staff 2 stated they were working on developing the menus as required but was short staffed and had not been able to complete it. Staff 2 indicated they had to change the menu to use up food supply. Staff 2 was asked if residents were notified in advance when menu items changed. Staff 2 stated they did try to let them know if and when they could. Staff 1 (Executive Director) was interviewed and acknowledged the facility currently did not have a system for communicating menu changes with residents per guidelines. Staff 2 (Dining Service Coordinator) toured kitchen areas with surveyor and acknowledged identified areas needing attention. At approximately 2:00 pm, surveyor reviewed above areas with Staff 1 (Executive Director), who acknowledged the findings.

Week at a glance menu, daily menus and weekly snack menu posted. All menus are signed off on by a registered dietitians. Snacks are accessible and available to residents 24 hours a day. Fresh fruit is available in the front lobby. Menu chat held twice monthly. During this meeting resident involvement in menu planning is highly encouraged. All substitutions will posted a accessible to residents prior to the meals via chalk board located outside the dining room in AL and on menu board in MC. Eco lab providing test strips for sanitation buckets that will be changed every two hours. Staff will be trained on this process during all staff meeting. Eco lab representative has been contacted to check the sanitizing chemical dispenser. Kitchen staff will be presented with and trained on updated daily cleaning tasks. Heavily used kitchen equipment/small appliances such as microwave, can opener and mixer have been added to daily and as needed cleaning tasks. Kitchen vents and pipes have been cleaned and added to TELS for scheduled twice a month cleaning. Kitchen window screens have been replaced. Kitchen staff have been trained on use of scoops for food bins. Sign with reminder of this direction can be found located near the bins. Dish washing rack have been cleaned and sanitized. This will be done on an ongoing basis. Floors and walls in dish pit have been cleaned and sanitized. All non-cleanable surfaces will be repaired. This area has also been added to routine cleaning schedule. Community has been contacted 3rd party company to have tiles in walk-in cooler/freezer repaired. This has been completed. Uncleanable surfaces on wall in dining area will be repaired and repainted. Walk-in freezer has been de-iced and added to weekly and as needed task list. Proper food storage and labeling will retrained and is being checked daily with task sheet and overseen by kitchen manager. Beard nets are now available to staff with facial hair and being used as required. Proper use of gloves/hand hygiene has been trained including no double gloving. Personal drinks will have lid/straw as required in kitchen area. Snack fridge now has a temp log and thermometer to ensure proper temp holding. Infection prevention policy binder is available to all kitchen staff. Crandall Corp. Dietitians services have been obtained and to ensure continued compliance. weekly audits to be completed by Administrator. New task sheets for cleaning tasks presented during all staff meeting. DSC will complete cleaning audits 5 days a week. Menu chat will held once monthly where concerns will be addressed. Comment cards and grievance log will be reviewed five times weekly by ED and followed up on in a timely manner.

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).

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 change of ownership survey, conducted 04/08/24 through 04/12/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations. Refer to deficiencies in report.

1) Residents were not directly affected by this alleged deficient practice. 2) An Oregon licensed administrator and an experienced Operations Specialist have been assigned to the community to oversee the day-to-day operations and to implement Brookdale Policies and Procedures. 3) District team members and/or Brookdale clinical specialists will connect with the community team a minimum of twice weekly via in person visits, training/support calls, and/or remote documentation review. This additional monitoring will continue for the months of May and June. 4) Facility has entered into an agreement with a Department-approved Registered Nurse Consultant whose first visit will be on or before __________, 2024. The District team, in collaboration with the ED and Operations Specialist, will be responsible for the corrections.

Based on interview and record review, it was determined the facility failed to develop and implement an effective method for responding to and resolving resident complaints. Findings include, but are not limited to: During the survey, interviews were conducted with sampled and unsampled residents, individually and as part of a group interview. Resident council meeting minutes were reviewed. Residents stated they were not aware of a way to voice complaints and have them be responded to by the facility. They had not seen or heard of a response to grievances brought forth and documented in resident council meetings. During interviews on 04/11/24 and 04/12/24, Staff 1 (Acting ED) and Staff 4 (District Director of Operations), stated that resident council meeting minutes were reviewed by the Activity Director. They stated they were not aware of how the minutes were currently being addressed or responded to. They stated that complaints could be addressed at the resident town hall meetings as well, but did not currently have any documentation supporting this. They stated that there was a grievance binder which should have been available to residents, but did not know where it currently was or who would respond to complaints written in the binder. The need to ensure the facility developed and implemented written policies and procedures for responding to and resolving resident complaints was discussed with Staff 1, Staff 3 (District Director of Clinical Operations/RN), and Staff 4 on 04/12/24. They acknowledged the findings.

1) Community residents or their legal representatives will receive a copy of the community's grievance procedure in writing by 5/8/24. 2) A copy of the community's grievance policy will be given to new residents at the time of move-in. 3) The Executive Director (ED) or designee will maintain and review the grievance binder weekly for new concerns and to confirm that grievances have been responded to by management. 4) The ED or designee will share areas identified in a grievance along with the resolution at the community's monthly Town Hall and Resident Council.  The ED or designee will also discuss with specific residents who bring forward a grievance if they disclosed their identity in the written concern.  The ED will be responsible for the corrections.

Based on observation, interview, and record review, it was determined the facility failed to ensure reasonable precautions were taken to ensure residents' health and safety related to modified diet texture for 1 of 1 sampled resident (#6). Findings include, but are not limited to: Observation of meals, interviews with staff, and review of the Brookdale Diet Manual identified the following: Resident 6 had a diagnosis of dysphagia and a signed physician order for a "Texture Modified diet." On 04/09/24, Staff 3 (District Director of Operations/RN) stated a Texture Modified diet was defined by Brookdale, and provided a copy of the Brookdale Dietary Manual. The manual stated "all meat and poultry is ground," and foods to avoid include "raw lettuce and leafy greens." On 04/08/24 and 04/09/24, Resident 6 was served meals which contained foods outside of this therapeutic diet for swallowing safety, including sausage links, barbeque chicken shredded with a fork into one inch long pieces, and a wrap which included romaine lettuce and chicken which was not ground. The above meals were prepared by three separate cooks, including the dietary services manager. They identified that the resident should be receiving a Texture Modified diet, but were not able to clearly state what should be done to meat or what foods needed to be avoided. The need for the facility to exercise reasonable precautions by ensuring residents received the therapeutic diet for swallowing safety, as ordered by their physician, was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN) and Staff 4 (District Director of Operations) on 04/09/24 and 04/12/24. They acknowledged the findings.

1.) Resident 6's dietary instructions were reviewed with dietary staff to confirm that a textured modified diet is served. 2) Dietary staff will be re-educated on the requirements for modified diets and the use of the daily diet modification summary report in accordance with community policies and procedures. Caregiving staff will be re-educated on what to expect when a resident is receiving a modified diet. For new dietary staff hired, training will be provided on modified diets and daily diet modifiers. The Brookdale Diet Manual will be available in the kitchen for dietary staff to review and refer to when providing meals with dietary modifications and/or restrictions. 3) Clinical department will send Dining Services Manager a nutrition tracker weekly listing residents on modified diets. 4) Dietary staff will place modified diet stickers on the side of plates as additional indicator for servers who are delivering meals and for caregivers who are assisting residents in the dining room.  The Dining Services Manager will be responsible for the corrections.

Based on observation, interview and record review, it was determined the facility failed to ensure residents received services in a manner that protected dignity and maintained a safe and homelike environment. Findings include, but are not limited to: 1. On 04/10/24, the surveyor was in Resident 3's apartment to interview the resident and make observations. The resident had been identified as diabetic, and was receiving sliding scale insulin. At 11:46 am, the resident's lunch was delivered to his/her room by kitchen staff. It was noted the meal was delivered in a Styrofoam container with plastic eating utensils. Resident 3 briefly looked at the meal, but made no attempt to begin eating. When the surveyor asked if s/he did not like the food, the resident replied, "Well, they've told me I have to wait until my blood sugar gets checked and I get my insulin before I can eat." The surveyor remained in the room, interviewing the resident. At 12:31 pm, after the meal had been sitting untouched for 45 minutes, Staff 15 (MT) entered the room. The MT administered an injection of Lantus (25 units), checked the resident's CBG, and administered Novolog (8 units). At this time, Staff 15 told Resident 3 s/he could eat lunch. These observations of the Styrofoam and plastic utensils, as well as the unreasonable wait time to eat, were considered violations of basic resident rights to dignity and a homelike environment. 2. In response to multiple resident complaints about the meals, the survey team requested two sample lunch trays on 04/11/24. This included one regular meal and one altered texture meal. The meal consisted of baked chicken, pasta, and vegetables. The team concluded the meal was not palatable due to the chicken being dry and stringy, making it very difficult to cut, especially with plastic utensils. In an interview on 04/10/24, a family member of an unsampled resident was quoted as saying "Food is always a problem ...we bring meals from home for my [family member]. The chicken is tough and hard, it's hard to chew. Because it's tough, so many residents can't cut up their meat so we'll help with that." On 04/12/24, the need to ensure all residents received services in a manner which protected dignity and fostered a safe and homelike environment was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Clinical Operations). They acknowledged the findings. 3. Resident 7 was admitted to the facility in 11/2022 with diagnoses including vascular dementia. Observations of Resident 7 during survey on 4/10/24 and 4/11/24 identified the following behaviors: * While inside his/her apartment, Resident 7 slammed his/her door and yelled inaudible words that were heard in the hallway. * While in the dining room waiting for lunch to be served, Resident 7 slammed his/her hand on the table, and residents responded by turning to look toward the sound of the noise. During the group interview on 04/09/24, multiple unsampled residents identified Resident 7 as having behavior issues that included screaming and yelling in his/her room, dining room, entryway to the facility, and facility hallways. They also stated that a resident living across the hall from him/her had verbalized s/he did not feel safe at times due to this person's behaviors. In various one-on-one interviews, facility residents made the following statements regarding Resident 7's behaviors: * "[S/he] got in an uproar and started screaming and hollering and banging on [his/her door] at night. It woke me up and went on and on at like two, three, four and five in the morning." * "[S/he] had gestured like [s/he] would hit someone." * "I have locked my door and felt safe only because others were around." * "[S/he] had run into other residents' walkers, banged on furniture, or [his/her] cup on the table because [s/he] didn't get [his/her] way." * "[Resident] was so loud and disturbed all of us, [s/he] made such a racket and everyone could hear [him/her]." During an interview with an unsampled resident s/he stated "This has been going on since [s/he] has lived here. I don't feel like the Administrator cares about us at all. I thought about calling newspapers to get some action because nobody cares as long as they keep getting money." S/he confirmed the Administrator had been notified of Resident 7's behavior "and the Administrator keeps saying that they are working on it." Multiple caregivers interviewed stated they were aware of Resident 7's behaviors and were aware that unsampled residents had verbalized fear of Resident 7. They stated MTs and nursing staff had been informed. Resident council notes from 03/08/24 were observed posted in the facility's hallway. Under the title "Administration", notes were written that stated, "[Resident who lived across the hall from Resident 7] asks what is going on with [Resident 7]? There are residents who are afraid of [him/her]." Staff 1 (Acting ED) and Staff 5 (Health and Wellness Coordinator/LPN) were observed walking along the hallway where the minutes were posted multiple times during the survey. During an interview on 04/09/24 with Staff 1 and Staff 5, they indicated they were not aware of Resident 7's behaviors affecting other residents. They stated that Resident 7 was hard of hearing, therefore talked and sang loudly which was perceived by other residents as yelling. They acknowledged the need to investigate the behaviors and provided temporary service plans for staff to address the behavior. The need to ensure residents had a safe and homelike environment related to a resident's behavior was discussed with Staff 1, Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings.

1) ED ordered additional china and flatware, and a new heated transport cart for meal tray service to residents rooms. Staff will be re-educated on timely service to  residents receiving room tray delivery for meal service. The service plan for Resident 7 will be updated to include interventions to address this resident's behavioral expressions. 2) Residents will be served with china and flatware when receiving meal tray service delivered to their room, unless resident preference is otherwise. If resident requests use of styrofoam, this will be listed in service plan.   3) Room service orders and delivery procedure will be reviewed with staff and residents to implement an efficient system for residents including the ordering process and times of delivery and pick up.  Associates  will be educated on the revised procedure.  For the month of May, room tray meal deliveries will be monitored every other day by the ED or designee.  After the month of May, the room tray meal delivers will be monitored weekly by the ED or designee. 4) The  ED and Dining Services Manager will be responsible for these corrections.

2. Resident 7 was admitted to facility in 11/2022 with diagnoses including vascular dementia. Resident 7's 01/09/24 through 04/10/24 progress notes, incidents reports, 03/19/24 service plan, and temporary service plans (TSPs) were reviewed. a. During the group interview on 04/09/24 at 2:00 pm, multiple unsampled residents identified Resident 7 as having behavior issues that included screaming and yelling in his/her room, dining room, entryway to the facility, and facility hallways. They also stated that a resident living across the hall from him/her had verbalized s/he did not feel safe at times due to this person's behaviors. During an interview on 04/09/24, Staff 23 (Resident Assistant) indicated Resident 7 had wandered into another resident's room uninvited. On 04/09/24 at 5:30 pm this information was brought to the attention of Staff 1 (Acting ED), and an investigation was completed by the administrator and confirmed the behavior occurred. The incident was immediately reported to the local SPD office. b. Review of Resident 7's progress notes identified the following: * 01/13/24 - A Resident Assistant found "a large bruise on the underside of [his/her] left arm ... also a small skin tear maybe ½ or 1 inch long"; and * 01/27/24 -  Resident [7] yelled at another resident "that [s/he] wishes [s/he] could kill the resident's dog." The facility lacked documented evidence the reported abuse and suspected abuse was reported to the local SPD office immediately and investigation into the suspected abuse included an Administrator's review. During an interview on 04/12/24 with Staff 1 (Acting ED), she confirmed the reported abuse was not reported to the local SPD office and the investigations into the reports of abuse lacked documentation of an Administrator's review. The need to ensure reports of abuse were immediately reported to the local SPD office and investigations into reported abuse included an Administrator's review was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. The findings were acknowledged. The facility was directed to self-report the incidents to the local SPD office. Confirmation of the report was received on 04/12/24 prior to survey exit. 3. Resident 6 was admitted to the facility in 09/2023 with diagnoses including generalized anxiety disorder and dementia. Staff were interviewed, and the resident's 03/01/24 through 04/07/24 MAR, progress notes, incident investigations, and temporary service plans were reviewed. The following was identified: * Inconsistencies were present between the MAR and log book for 10 doses of alprazolam (for anxiety), a controlled substance; and * The resident was administered greater than the maximum prescribed dose of acetaminophen (for pain) during four 24-hour periods. There was no documented evidence the above medication errors had been investigated at the time of occurrence, the investigations included all required components, or the incidents were reported to the local SPD office if abuse could not be reasonably ruled out. The need to ensure all incidents were promptly investigated, contained all required areas of documentation including if abuse could be ruled out, and if not, were reported to the local SPD office, was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings. The facility provided documentation that the incidents were reported on 04/12/24. Refer to C302, and C303.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause, unwitnessed falls, behaviors, and medication errors were promptly investigated to rule out suspected abuse and/or neglect and were reported to the local SPD office as needed for 3 of 5 sampled residents (#s 4, 6, and 7). Findings include, but are not limited to 1. Resident 4 was admitted to the facility in 04/2023 with diagnoses including chronic kidney disease, hypertension, tremor, and weakness. Review of the resident's record, including the 03/15/24 service plan, 01/08/24 through 04/08/24 progress notes, temporary service plans (TSPs), and incident reports was completed. Interviews were conducted. The following was identified: * 01/20/24 - Non-injury fall; * 02/06/24 - Fall, after which the resident stated s/he had hit his/her head; * 03/10/24 - Return from hospital with "wound on [his/her] right wrist"; and * 03/23/24 - Non-injury fall. There was no documented evidence these incidents were investigated to rule out abuse and/or neglect or were reported to the local SPD if abuse and/or neglect could not be ruled out. The facility was asked to report the 02/06/24 and 03/10/24 incidents on 04/11/24 at 10:18 am. Confirmation of the reports was received prior to survey exit. The need to investigate all incidents promptly and to report incidents to the local SPD if abuse and/or neglect could not be ruled out was discussed with Staff 3 (District Director of Clinical Operations/RN) and Staff 4 (District Director of Operations) on 04/18/24. They acknowledged the findings.

1) The incidents identified during the survey were reported to APS prior to survey exit on 4/12/2024. 2) Community associates will receive training on "Elder Abuse Prevention, Investigation and reporting" provided by Oregon Care Partners online education series.  Community management will receive will be re-educated on Brookdale policies and procedures related to investigating and reporting incidents. 3) Incidents will be reviewed 4-5 days a week during regular scheduled clinical meeting. This review will confim that incidents have been properly investigated and reported to APS as appropriate. 4) The Executive Director, Health and Wellness Director and/or designees will be responsible for the corrections.

Based on observation, interview, and record review, it was determined the facility failed to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and that created opportunities for active participation in the community at large. Findings include, but are not limited to: During the survey, the facility was home to 59 residents. Resident observations were made between 04/10/24 through 04/12/24, the activity calendar was reviewed, and staff were interviewed. The following was revealed: a. The April 2024 Activity Program calendar provided to the survey team indicated the following activities would occur on 04/11/24: * 9:30 am - B-Fit Arm and Legs; * 10:30 am - Pastor Ben; * 1:15 pm - Manicures; * 2:00 pm - Movie Matinee; * 3:00 pm - Cocktail Hour; and * 6:30 pm - Nick at Night. On 04/11/24, B-Fit Arm and Legs and Movie Matinee were not observed to occur. However, an additional activity of a Scenic Drive was offered, which was previously scheduled for 1:15 pm on 04/10/24. b. On 04/12/24  the activity calendar noted the following activities would occur in the morning: * 9:30 am -  B-Fit with Claire; * 10:00 am - Hydration Station; and * 11:00 am - Felt Painting - Crafts. There was no facility-led activity observed during the morning of 04/12/24. Staff 9 (Resident Programs) was observed to assist in covering front office duties, and stated she would leave out the items for the residents to self-direct the Felt Painting. c.  During an interview on 04/12/24 at 9:50 am, Staff 9 reported she worked Monday through Friday from 8:30 am to 4:30 pm. On the weekends, all of the activities were self-directed by the residents, and she left a basket out for ideas in the activity room. She reported the facility had started using an Engagement Profile form to identify a resident's interest and preference in activities, however, not every resident had a completed form yet. d. Interviews with residents revealed the following: During a group interview with unsampled residents on 04/09/24, residents stated: * "There are no activities on the weekend."; and * "Whenever I try to come to an activity, it's been canceled and no one is there." On 04/10/24, Witness 1 stated, "These residents are dying of boredom. They never have any activities going on or there are excuses. All I have ever seen is Bingo." Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings.

1) An activity calendar is posted monthly to include a variety of activites that are staff led as well as resident directed and will occur at scheduled times unless otherwise indicated. 2) Community staff will be re-educated on resident engagement activities and how to lead an activity with residents. 3) Scheduled activities and staff coverage will be reviewed daily at Stand Up meeting Monday-Friday, and weekend activity coverage will be reviewed on Fridays. On days where the Resident Engagement Coordinator is unavailable, staff will be designated by ED or designee to faciliate scheduled activities. 4) The ED and Resident Engagement Coordinator are responsible for the corrections and weekly monitoring.

Based on interview and record review, it was determined the facility failed to include all required elements on a move-in evaluation and failed to ensure quarterly evaluations described resident's physical health status, mental status and the environmental factors that help the resident function at their optimal level, and were relevant to the current needs and condition of the resident, for 2 of 5 sampled residents (#s 5 and 6) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 03/2024 with diagnoses including Type 2 diabetes and left below-the-knee amputation. Review of the move-in evaluation, dated 02/27/24, identified the following required elements were not documented as being addressed: * Customary routines: bathing; * Cognition, including decision making abilities; * Activities of daily living, including: toileting, bowel and bladder management; dressing, grooming, bathing and personal hygiene; mobility, ambulation and transfers; and eating; * Pain, including pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Skin condition; * Treatments, including type, frequency and level of assistance needed; * Indicators of nursing needs including potential for delegated nursing tasks; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful prior placements; and * Environmental factors that impact the resident's behavior including noise, lighting and/or room temperature. The need to ensure move-in evaluations include all required elements was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN) and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 09/2023 with diagnoses including generalized anxiety disorder and dementia. The resident's most recent evaluation, dated 04/02/24, was reviewed and interviews were conducted. Multiple areas of the evaluation did not describe Resident 6's current physical and mental status, environmental factors which helped the resident function at his/her optimal level, and/or were not relevant to the resident's current condition, including: * Evacuation status; * Diet texture; * Interests and activities; * Environmental factors that impact the resident's behavior, including noise; * Bathing habits and preferences; * History of depression; * Cognition including orientation to time; * Ability to use call pendant; * Ability to manage medications including self-directing PRN medications; * Pain; and * Anxiety and behaviors. The need to ensure evaluations described resident's physical health status, mental status, and the environmental factors that helped the resident function at their optimal level, and were relevant to the current needs and condition of the resident was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings.

1). The quarterly evaluation for Resident 6 was reviewed and updated to address each of the areas required under the rule.  A quarterly evaluation will be completed for Resident 5 to address each of the areas required by the rule.   2) Community nurses completing resident evaluations will be re-educated on how to complete and address each of the areas required by the rule.   3) The ED or designee will review the PSS Due and Error report weekly to verify which evaluations are due for residents.  The ED or designee will then review the completed evaluations to confirm that they address each of the areas required under the rule.  Care conferences will be scheduled with ED or designee and residents and/or responsible parties to review any changes with the evaluation. 4) The ED and community nurses will be responsible for the corrections and monitoring.

2. Resident 1 moved into the facility in 03/2022 with diagnoses including stroke, chronic obstructive pulmonary disease, and chronic kidney disease. The current service plan, dated 03/13/24, and progress notes from 01/16/24 through 04/07/24 were reviewed. Observations and interviews with staff and Resident 1 were completed during the survey. The following was identified: The service plan lacked information and instructions for providing care in the following areas: * Left side paralysis; * Two-person assist with ADLs; * Verbally aggressive behaviors towards spouse and staff; * Physical altercations with spouse and staff; and * Interventions for aggressive behaviors and altercations. The need to ensure the service plan reflected Resident 1's care needs and included clear directions to staff regarding the delivery of services was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/11/24. They acknowledged the findings. 3. Resident 2 moved into the facility in 03/2022 with a diagnosis of hearing loss. Observations and interviews with staff and Resident 2, and a review of the resident's most current service plan, dated 01/11/24, showed the service plan did not provide clear direction to staff in the following areas: * Resident did his/her and spouse's laundry; * Resident administered spouse's medication; * Resident had three pets in his/her apartment; * Routinely skipped lunch with spouse, due to poor quality of food from the facility kitchen; * Provided ADL assistance to spouse; and * Spouse's verbal and physical behaviors including interventions to ensure both resident and spouse were safe. The need to ensure service plans reflected current care needs and provided clear direction to staff was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/11/24. They acknowledged the findings. 4. Resident 3 was admitted to the facility in 09/2017 with diagnoses including hypertension, Diabetes (Type II), and congestive heart failure. Review of Resident 3's service plan, dated 03/15/24, interviews with staff, and observations during the survey revealed the service plan was not reflective of the resident's current care needs and/or did not provide clear instruction to staff in the following areas: * Timing of meals related to glucose checks and insulin administration; * Cueing for activity participation; * Facilitating recommended PT exercises; * Encouraging ambulation; and * Evacuation status. On 04/12/24, the need to ensure service plans were reflective and provided clear direction for staff was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations). 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' needs, provided clear direction regarding the delivery of services, and services were implemented for 6 of 7 sampled residents (#s 1, 2, 3, 5, 6, and 7) whose records were reviewed. Findings include, but are not limited to: 1. Resident 7 was admitted to facility in 11/2022 with diagnoses including vascular dementia. The current service plan, dated 03/19/24, and Temporary Service Plans from 01/25/24 to 04/11/24 were reviewed. Observations of the resident and interviews with staff were completed during the survey. The service plan was not reflective of the resident's current status, did not provide clear direction to staff, and/or was not being implemented in the following areas: * Fall precautions, including frequency of safety checks and location of mattress against the wall; * Suicide talk interventions; * Assistance with toileting; * Taking meal order and delivery of food prior to escort into dining room; * Evacuation status; and * Hearing devices, including use of a voice enhancer. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. The findings were acknowledged. 5. Resident 5 was admitted to the facility in 03/2024 with diagnoses including Type 2 diabetes and left below-the-knee amputation. Observations of the resident, interviews with staff and the resident, and review of the resident's service plan, dated 03/07/24, and progress notes, dated 03/07/24 through 04/07/24, were completed. The service plan was not reflective and/or lacked resident-specific direction for staff in the following areas: * Carbohydrate-controlled diet; * Assistance required for dressing, grooming, transfers, bathing, toileting; * Resident-specific fall prevention instructions; * Skin condition and care; * Use of limb protector; * Ability to use key; * Evacuation ability and assistance required; and * Behaviors, including inappropriateness toward staff. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings. 6. Resident 6 was admitted to the facility in 09/2023 with diagnoses including generalized anxiety disorder and dementia. Observations of the resident, interviews with staff and the resident, and review of the resident's service plan, dated 04/02/24, and progress notes, dated 01/08/24 through 04/07/24, were completed. The service plan was not reflective and/or lacked resident-specific direction for staff in the following areas: * Hearing loss and level of assistance required for use of assistive devices; * Refusal of care and preference for showers one time per week; * Interests and activities, including walking; * Use of key and preference; * Medications, including PRN alprazolam (for anxiety); * Diet texture and appropriate snacks; * Level of assistance required for dressing, grooming, toileting; * Orientation to time; and * Behaviors related to anxiety. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings.

1) The service plans for Residents 1, 2, 3, 5, 6, and 7 were reviewed and updated to reflect current resident needs and provide clear direction on the delivery of services.  Staff will be educated on how to implement these updated service plans. 2) The service plans for the other residents will be reviewed and updated as necessary to verify that they reflect current needs and provide clear direction of the delivery of services by staff to residents. Current resident service plans will be available to staff in the TSP room. Community clinical leaders will be re-trained on the service plan process for residents.   3) Service plans will be reviewed and updated quarterly and upon change in condition. 4) The community clinical leaders will be responsible for the corrections and monitoring.

2. Resident 1 moved into the facility in 03/2022 with diagnoses including stroke, chronic obstructive pulmonary disease, and chronic kidney disease. The resident's service plan, dated 03/13/24, temporary service plans, incident reports, and progress notes, dated 01/16/24 through 04/07/24, were reviewed. Observations and interviews with staff and Resident 1 were completed during the survey. There was no documentation resident-specific actions or interventions had been determined or communicated to staff on all shifts, or that changes were monitored, with progress noted at least weekly through resolution, for the following changes of condition: * 01/16/24 - "The resident was found laying on [his/her] side with head laying on pillow and feet pointing towards the toilet, the resident complained of pain in left hip area but there was no apparent injury at the time"; * 01/16/24 - The resident was observed to have blood in his/her nephrostomy bag; * 02/20/24 - The resident was making racist comments about staff; * 03/18/24 - Staff to empty nephrostomy bag every shift and PRN if full and to notify the nurse if less than 100 ml; * 03/22/24 - "The resident was dizzy and unable to transfer three times when [s/he] was getting up for the day"; * 03/22/24 - "The resident had attempted to hit [his/her] spouse again tonight"; * 04/04/24 - The resident was verbally and physically aggressive towards a caregiver; and * 04/05/24 - The resident's nephrostomy bag and tube were red and the resident refused to go to the emergency room. The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, communicated to staff on each shift, and conditions were monitored, with progress documented at least weekly through resolution, was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/11/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents with changes of condition were evaluated, interventions were determined , implemented and communicated to staff on all shifts, and conditions were monitored at least weekly to resolution for 5 of 6 sampled residents (#s 2, 4, 5, 6, and 7). Findings include, but are not limited to: 3. Resident 7 was admitted to facility in 11/2022 with diagnoses including vascular dementia. Observation of Resident 7, interviews with staff, and review of the resident's 03/19/24 service plan, 01/09/24 through 04/10/24 temporary service plans (TSPs), progress notes, and incident investigations were completed. a. Resident 7 was identified to have the following behaviors: * 01/27/24 - Resident 7 yelled at another resident "that [s/he] wishes [s/he] could kill the resident's dog ...This resident also thru [sic] [his/her] walker at the elevator."; * 01/27/24 - "stating [s/he] wishes [s/he] could just die."; * 02/17/24 - Resident was yelling ... telling people to shut up. [S/he] yells at the residents and staff when walking by ..."; * 02/24/24 - "The resident was acting very aggressive towards another resident ..."; * 02/26/24 - Resident 7 made "a semi threatening gesture toward another resident saying 'you won't like me will you.'"; and * 03/24/24 - Resident 7 "repeatedly opened [his/her] apartment door and slammed it shut." During the group interview on 04/09/24, multiple unsampled residents identified Resident 7 as having behavior issues that included screaming and yelling in his/her room, dining room, entryway to the facility, and facility hallways. They also stated that a resident living across the hall from him/her had verbalized s/he did not feel safe at times due to this person's behaviors. During an interview on 04/09/24, Staff 23 (Resident Assistant) indicated Resident 7 had recently wandered into another resident's room uninvited. On 04/09/24 at 5:30 pm this information was brought to the attention of Staff 1 (Acting ED), and an investigation was completed by the facility and confirmed this behavior occurred. On 04/10/24 a TSP was provided that included "Increase checks and offer reassurance" and walk the resident's hall frequently to ensure "[his/her] and other residents safety." An updated TSP was requested by the surveyor on 4/11/24 that provided additional specific instruction to staff when Resident 7 was aggressive and/or made depressive/suicidal statements and included how to keep Resident 7 and other residents safe from harm. On 04/12/24 a copy of two TSPs were received that provided the requested interventions. b. Resident 7 had the following five falls: * 01/25/24 - non-injury fall, rolled out of bed; * 02/04/24 - non-injury fall, located "by bedside"; * 02/24/24 - non-injury fall in dining room; * 04/06/24 - fall with injury to the head in bedroom; and * 04/07/24 - non-injury fall in bedroom. On 01/25/24 a TSP instructed staff to ensure the resident's mattress was "pushed all the way against [his/her] wall" and "check on resident 4 [times] each shift." After the second fall a new intervention was identified to "encourage resident to use call light." Following the third fall, new interventions were to "escort resident to and from the dining room." Investigations of the second and third falls did not include evaluation of previous fall interventions, and the record lacked evidence whether fall interventions were being implemented or were effective. The interventions identified for preventing falls were not included in the resident's current service plan, which had been updated on 03/19/24. c. On 02/22/24 Resident 7 complained of chest pain. There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident, communicated the actions or interventions to staff on each shift, or monitored the condition with progress noted at least weekly through resolution for his/her chest pain. d. On 1/13/24 a "large bruise on the underside of his left arm leading up into his armpit." Also, a "small" skin tear was identified, location not specified. The facility lacked documented evidence the skin was monitored at least weekly until resolution. During an interview with Staff 1, Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24, the facility's process for identifying changes of condition, developing interventions, communicating them to staff, and monitoring interventions for implementation and effective was discussed. Staff acknowledged the findings. 4. Resident 5 was admitted to the facility in 03/2024 with diagnoses including Type 2 diabetes and left below-the-knee amputation. The resident's clinical record, including progress notes and incident reports dated 03/07/24 through 04/07/24, were reviewed, the resident was observed, and interviews with staff were conducted. There was no documented evidence resident-specific actions or interventions for short-term changes of condition were determined, communicated to staff on all shifts, or were monitored, with progress noted at least weekly through resolution: * 03/09/24 - Wound to left arm; * 03/09/24 - Wound related to left below-the-knee amputation; * 03/26/24 - New medication/change in insulin dosage; * 03/27/24 - Inappropriate behavior toward staff; * 03/31/24 - Fall when entering bus due to wheelchair tipping backwards, resulting in right elbow abrasion; and * 04/03/24 - Discontinued PRN oxycodone (for pain). The need to ensure determined actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and monitored at least weekly through resolution was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings. 5. Resident 6 was admitted to the facility in 09/2023 with diagnoses including generalized anxiety disorder and dementia. The resident's clinical record, including progress notes and incident reports dated 01/08/24 through 04/07/24, were reviewed, the resident was observed, and interviews with staff were conducted. There was no documented evidence resident-specific actions or interventions for short-term changes of condition were determined, communicated to staff on all shifts, or were monitored, with progress noted at least weekly through resolution for the following: * 01/08/24 - New medication levofloxacin (for infection); * 02/14/24 - New onset of abdominal pain, resident requested to speak to nurse due to history of hernia; * 03/26/24 - New onset of right knee pain with significant increase in use of PRN pain medication over the following two weeks; and * 03/2024 through 04/2024 - Significant and consistent increase in use of PRN psychotropic medication for anxiety. The need to ensure determined actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and monitored at least weekly through resolution was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings. 1. Resident 4 was admitted to the facility in 04/2023 with diagnoses including chronic kidney disease, hypertension, tremor, and weakness. The resident's 03/15/24 service plan, 01/08/24 through 04/08/24 progress notes, temporary service plans (TSPs), weight records, and incidents were reviewed. Interviews were conducted. The following short-term changes of condition were identified: * 01/20/24 - Non-injury fall; * 02/06/24 - Fall, after which the resident stated s/he had hit his/her head; * 02/06/24 - Aggressive behavior toward staff; * 03/07/24 - 03/24/24 - Multiple possible missed medications; * 03/09/24 - Confusion and hallucinations; * 03/10/24 - Return from hospital with "wound on [his/her] right wrist"; and * 03/23/24 - Non-injury fall. There was no documented evidence the changes of condition the resident experienced were consistently evaluated, actions or interventions were consistently determined, communicated to staff on all shifts, and implemented, or were consistently monitored, with progress noted at least weekly through resolution. In addition, review of the resident's weight records identified a significant weight gain: * 12/06/23 - 154.7 pounds; and * 01/10/24 - 164.4 pounds. The resident gained 9.7 pounds, or 6.27% of his/her total body weight, in one month. This constituted a significant change of condition. There was no documented evidence the resident was evaluated after this significant change of condition, that staff referred the issue to the RN, the change was documented, or the service plan updated. The failure to ensure short-term changes of condition were evaluated, interventions were determined and implemented, and interventions were monitored for effectiveness, with progress noted weekly, and the failure to refer significant changes of condition to the facility RN was discussed with Staff 3 (District Director of Clinical Operations/RN) and Staff 4 (District Director of Operations) on 04/11/24. They acknowledged the findings.

1) Residents 2, 4, 5, 6, and 7 will be assessed by a nurse to determine whether any of the previous identified changes in condition are still in need of interventions.  If such changes have resolved, documentation was placed in the resident's record. 2) Education with community clinical team on Brookdale policies and procedures regarding significant and short term changes of condition and effective monitoring and assessment will be provided by District Director of Clinical Services. Medication technicians will receive education on recognizing and reporting residents experiencing a change of condition. 3) Community clinicall leaders will review progress notes and incident reports during regularly scheduled clinical meetings at least 4-5 times per week to identify changes in condition. 4) The ED and community clinical leaders will be responsible for the corrections and monitoring.

Based on interview and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#4) who experienced significant changes. Findings include, but are not limited to: Resident 4 was admitted to the facility in 04/2023 with diagnoses including chronic kidney disease, hypertension, tremor, and weakness. The resident's 03/15/24 service plan, 01/08/24 through 04/08/24 progress notes, temporary service plans (TSPs), weight records, and incidents were reviewed. Interviews were conducted. The following was identified: * 12/06/23 - 154.7 pounds; and * 01/10/24 - 164.4 pounds. The resident gained 9.7 pounds, or 6.27% of his/her total body weight in one month. This constituted a significant change of condition. There was no documented evidence a significant change of condition assessment was completed by an RN, including findings, resident status, and interventions made as a result of the assessment. Weight records indicated the resident had not experienced additional significant weight gain or loss since 01/10/24. On 04/09/24, Staff 5 (Health & Wellness Coordinator/LPN) reported she was unable to find any documentation related to the resident's significant weight gain in 01/2024. The need to ensure an RN assessed all significant changes of condition, including findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 3 (District Director of Clinical Operations/RN) and Staff 4 (District Director of Operations) on 04/11/24. They acknowledged the findings.

1) Resident 4 will be assessed by a nurse to determine whether the previously identified significant changes in condition are still in need of interventions.  If such changes have resolved, documentation was placed in the resident's record. 2) Education with community clinical team on Brookdale policies and procedures regarding significant and short term changes of condition and effective monitoring and assessment will be provided by District Director of Clinical Services. Medication technicians will receive education on recognizing and reporting residents experiencing a change of condition. 3) Community clinicall leaders will review progress notes and incident reports during regularly scheduled clinical meetings at least 4-5 times per week to identify changes in condition. 4) The ED and community clinical leaders will be responsible for the corrections and monitoring.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#3) who received sliding-scale insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task. During the acuity interview on 04/08/24, it was identified that Resident 3 received insulin injections by unlicensed (MTs) staff daily. Review of delegation documentation during the survey revealed the following: The initial delegation reviews for Staff 15 (MT), Staff 16 (MT/Resident Assistant), and Staff 18 (MT) lacked the following documentation: * The client did not require assessment during the procedure; * The procedure did not require interpretation or independent decision making; * Results of the procedure were reasonably predictable; * The procedure was not life-threatening, and delegation posed minimal risk to the client; * The client's environment supported safe performance of the procedure; * Availability of RN to provide ongoing assessment of the client at frequency deemed necessary to determine ongoing stability and predictability; * Availability of RN to provide ongoing competency validation of Unregulated Assistive Person's performance; * Updated the service plan to identify that procedure had been delegated; and * Documented recommendations on how the client would continue to receive the procedure if the RN was no longer a member of the health care team and the procedure remained ordered for the client. In an interview on 04/10/24 at 12:25 pm, Staff 3 (District Director of Clinical Operations/RN) reported she was aware of the current delegation requirements but had not yet updated the delegation form or binder to reflect OSBN Division 47 Rules. A copy of Division 47 rules was provided. The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Acting ED), Staff 3, and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings.

1) The community registered nurse will complete and document nurse delegation tasks for medication technicians (med techs) who will administer insulin to Resident 1. 2) The ED or designee will review the personnel files for medication technicians to verify the delegation documentation has been completed per Oregon regulations. 3) The ED or designee will review the nurse delegation documentation for any new med tech to confirm the necessary delegations have been provided before the med tech begins to provide any nurse delegated tasks. 4) The ED and community clinical leaders are responsible for the corrections and monitoring.

2. Resident 1 moved into the facility in 03/2022 with diagnoses including stroke, chronic obstructive pulmonary disease, and chronic kidney disease. Resident 1's record was reviewed and indicated the following: a. Documentation dated 01/04/24 from an outside provider identified the resident was seen at his/her apartment for a follow-up visit, after having his/her nephrostomy tube dislodged and replaced at the emergency room on 12/17/23. The documentation indicated Resident 1's spouse was confused about who was supposed to manage the nephrostomy tube and changes. There was no documented follow-up to the information left by the outside provider, nor was there documented evidence the facility assisted the resident in coordinating with outside providers. b. A progress note dated 01/16/24 documented that the resident's nephrostomy bag had blood in it, and staff were instructed to call the resident's urologist. Staff noted the resident's spouse was refusing to call the urologist and would not let the MT have the number to call. There was no documented evidence the facility had followed up with the urologist. c. A progress note dated 02/16/24 documented: "This [nurse] went to resident's room to view nephrostomy site. The dressing was clean and fully intact, and proper flow was present. There was no apparent redness under the dressing. The resident denied pain or any other difficulty." The resident stated, "[his/her] [relative] was an RN and had been there earlier in the week, and [s/he] changed the dressing." It was further documented that the nurse would check medical records to get a better timeline of how long the nephrostomy has been in place, and to ensure the facility followed the correct treatment plan. The nurse noted that she had "spoken with the spouse, who tried to describe the timeline of issues but was very jumbled with [his/her] dates and descriptions." The nurse indicated she would get back to the resident and spouse about the plan of care. There was no corresponding documentation regarding the resident's nephrostomy plan of care. d. An "After Visit Summary" dated 04/04/24 indicated the resident was referred to urology and HH. The LPN's progress note, dated 04/05/24, indicated that she had attempted to call the urology clinic, but the office had turned their phones to the answering service. There was no documented follow-up regarding care coordination between the facility, urology clinic, and HH. An interview on 04/09/24 with Resident 1 and his/her spouse indicated they were frustrated with the facility not coordinating HH services for Resident 1's nephrostomy care. They expressed frustration in driving to appointments and picking up supplies to obtain a urine sample. Resident 1's spouse reported having to collect the urine sample and then driving it to the clinic. During an interview on 04/11/24 with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations), the staff indicated that Resident 1's spouse often declined help and preferred to schedule and transport Resident 1 to his/her appointments. The need for an effective system for coordinating care with on-site and off-site healthcare providers to ensure continuity of care was discussed with Staff 1, Staff 3, and Staff 4 on 04/11/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure staff were informed of new interventions, adjust the service plan if necessary, ensure reporting protocols were in place, and assist residents by coordinating appointments with outside providers, that were necessary to support the resident's health needs for 2 of 5 sampled residents (#'s 1 and 5) who received outside services. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 03/2024 with diagnoses including Type 2 diabetes and left below-the-knee amputation. Resident 5's progress notes, dated 03/07/24 through 04/07/24, were reviewed, as well as all outside provider communications, dated 03/19/24 through 04/07/24. The following was identified: a. The facility did not receive or document outside provider notes and recommendations from home health nursing for wound care on the following dates: * 03/28/24; * 04/01/24; and * 04/04/24. b. The facility did not receive or document outside provider notes and recommendations from home health physical therapy on the following dates: * 03/20/24; * 03/22/24; and * 04/03/24. c. There was no documentation that the following recommendations from home health nursing regarding wound care were implemented: * 03/19/24: "Encourage a balanced diet + pressure relief [sic] strategies"; * 03/21/24: "Please do not get wet"; and * 03/25/24: "Please monitor for any excess drainage, dressing dislodgement or infection." d. A progress note on 03/12/24 stated Resident 5 "was supposed to be referred to a dermatologist for cancerous lesion on left arm," and "agreed we would make appointment and set up transportation to have lesion on arm evaluated. Receptionist to schedule." The resident and staff stated they were unaware of whether an appointment had been made and the lesion had not been evaluated as of 04/07/24. The need to coordinate care with outside providers, ensure staff were informed of new interventions, adjust the service plan if necessary, ensure reporting protocols were in place, and assist residents by coordinating appointments, with outside providers, that were necessary to support the resident's health needs was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings.

1) Service plans for Residents 2 and 5 were reviewed and updated to include the services provided by third parties and any coodination needed.  The services plans for any residents receiving services from outside providers will be reviewed and updated to include the services provided by such parties,  coordination directions, and ongoing interventions. 2) A memo will be sent to residents and/or their legal representatives notifying them to inform the ED or clinical leadership of any services provided by outside providers.  Community clinical leaders will reach out to those third party providers and will coordinate care and the delivery of regular progress notes to the community. 3) The ED and community clinical leaders will review third party notes during clinical meetings. 4) The ED and community clinical leaders will be responsible for the corrections and monitoring.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight.  Findings include, but are not limited to: During the relicensure survey, conducted 04/08/24 through 04/12/24, administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C 282: Systems: RN Delegation; * C 302: Systems: Tracking Controlled Substances; * C 303: Systems: Medication and Treatment Orders; * C 310: Systems: Medication Administration; * C 325: Systems: Self-Administration of Medications; and * C 330: Systems: Psychotropic Medication. On 04/12/24, the above information was shared with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations), and Staff 4 (District Director of Operations). They acknowledged the findings.

1) The community will identify a registered nurse to provide regular oversight and implementation of its medication and treatment administration systems. 2) The registered nurse will observe and evaluate the skills of the community's medication technicians and will provide re-education as needed based upon those assessment and Brookdale policies on medication and treatment administration. 3) A licensed nurse will complete a MAR to Cart audit weekly for the months of May and June.  The audit findings will be placed in the survey binder. 4) The ED and District Director of Clinical Services will be responsible for the corrections and monitoring.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 3 sampled residents (#s 4 and 6) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 09/2023 with diagnoses including generalized anxiety disorder and dementia. The resident had a signed physician order for scheduled alprazolam (for anxiety), 0.5 mg tablet administered every night "at bedtime." The resident also had an order for PRN alprazolam (for anxiety), 0.5 mg tablet, to be administered every eight hours as needed. Alprazolam is the generic name for Xanax, and is a controlled substance. Review of the resident's 03/01/24 through 04/07/24 MARs and the Controlled Substance log revealed the following: On the following dates, alprazolam (scheduled or PRN, as noted below) was shown as administered on the MAR, but was not documented in the Controlled Substance Distribution log: * 03/01/24 scheduled; * 03/03/24 scheduled; * 03/10/24 scheduled; * 03/10/24 PRN at 0953; * 03/11/24 PRN at 0831; * 03/20/24 PRN at 1223; and * 03/26/24 PRN at 0104. On the following dates, alprazolam was not documented as administered on the MAR, but was documented as administered in the Controlled Substance Disposition log: * 03/12/24 PRN at 0942; * 03/19/24 PRN at 1222; and * 03/28/24 PRN at 1202. On the following dates, scheduled alprazolam was documented as administered in the PRN alprazolam log book and medication card: * 03/11/24 at 2055; * 03/17/24 at 1948; * 03/18/24 at 1944; * 03/20/24 at 2025; * 03/24/24 at 2050; * 03/25/24 at 2045; * 04/05/24 at 1955; and * 04/07/24 at 1955. On the following dates, PRN alprazolam was documented as administered on the scheduled alprazolam log book page and medication card: * 03/31/24 at 1004; * 03/31/24 at 1754; and * 04/02/24 at 0826. The number of tablets remaining on the medication cards matched the number of tablets indicated in the disposition logs for both scheduled and PRN alprazolam. During an interview on 04/11/24 with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations), Staff 3 stated the facility was not aware of the above discrepancies. The need to ensure a system was in place for accurately tracking controlled substance distribution was discussed with Staff 1, Staff 3, and Staff 4 on 04/12/24. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 04/2023 with diagnoses including chronic kidney disease, hypertension, tremor, and weakness. The resident's 03/01/24 through 04/10/24 MARs and physician orders were reviewed. Interviews were conducted. There was an entry on the resident's MARs for hydrocodone/APAP 5-325 mg tab, one tablet by mouth twice daily as needed for pain. On 04/10/24 the Controlled Substance Distribution log was compared to the resident's medication card and 03/01/24 through 03/31/24 MAR. The following discrepancy was noted: * On 03/30/24 at 0900 a tablet was removed from the medication card; and * There was no corresponding entry on the resident's 03/01/24 through 03/31/24 MAR that the medication had been administered to the resident. The number of tablets remaining on the medication card matched the number of tablets remaining documented on the corresponding Controlled Substance Distribution log page. The need to ensure all medications removed from the medication cards were initialed as administered on the MAR, or the reason why the medication was not administered was documented, was discussed with Staff 3 (District Director of Clinical Operations/RN) and Staff 4 (District Director of Operations) on 04/11/24. They acknowledged the findings.

1) Community clinical leaders will implement the Brookdale system for tracking controlled substances. 2) Community clinical leaders will educate the medication technicians on the Brookdale policy and procedure for tracking controlled substances. 3) A licensed nurse will audit the controlled substances logs weekly for the months of May and June.  The audit findings will be placed in the survey binder. 4) The ED and community clinical leaders will be responsible for the corrections and monitoring.

2. Resident 3 was admitted to the facility in 09/2017 with diagnoses including Type 2 diabetes. Resident 3's MARs, dated 03/01/24 through 04/08/24, corresponding progress notes, and prescriber orders were reviewed. a. Resident 3 had a physician's order dated 03/12/24 for insulin as part to inject eight units under the skin with meals, plus sliding scale based on fasting blood sugar as follows: * Less than 150: No insulin; * 150 - 199: 1 unit; * 200 - 249: 2 units; * 250 - 299: 3 units; * 300 - 349: 4 units; and * 350 - 400: 6 units. The scheduled eight units of insulin and the sliding scale insulin with CBG on Resident 3's MAR to be administered at 8:00 am, 12:00 pm, and 5:00 pm, were transcribed separately. On 03/16/24, the facility faxed a request to the physician to consider discontinuing the 8:00 am dose of the aspart insulin due to Resident 3 not eating breakfast, which was signed and faxed back by the prescriber on 03/19/24. The facility failed to update Resident 3's MAR to reflect the discontinuation of the 8:00 am sliding scale insulin aspart and CBG. Between 03/20/24 and 04/08/24, the facility took 8:00 am CBGs on Resident 3 on 11 occasions. There was no sliding scale insulin administered during that time period. During an interview on 04/11/24 at 3:20 pm, Staff 3 (District Director of Clinical Operations/RN) confirmed that the 8:00 am CBG and sliding scale insulin should be discontinued from Resident 3's MAR, and she was unsure why the pharmacy had not discontinued it. Both the CBG and sliding scale insulin for 8:00 am were observed to be discontinued on the electronic MAR by surveyor on 04/12/24 at 10:04 am. b. On 04/10/24 at 12:32 pm, Staff 15 (MT) was observed administering an injection of Lantus (25 units) to Resident 3. The surveyor asked the MT whether this insulin dose was scheduled to be given at 8:00 am (4.5 hours earlier). Staff 15 stated the MT at that time was agency and not delegated to perform the task, so the insulin was being administered late. The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Acting ED), Staff 3, and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings, and no additional information was provided. 3. Resident 5 was admitted to the facility in 03/2024 with diagnoses including Type 2 diabetes and left below-the-knee amputation. Resident 5's MARs, dated 03/07/24 through 04/08/24, corresponding progress notes, and physician's orders were reviewed. The following was identified: a. There were no signed physician orders in Resident 5's chart for the following treatments: * Daily CBG's; and * Wound care to left arm, left below-the-knee amputation, and right elbow. b. The following medications had signed physician's orders, but were not being administered: * Ascorbic acid (supplement); and * Coenzyme Q10 (supplement). c. The resident had an order for furosemide 20 mg tablet (for heart failure) to be administered daily. The order also stated, "Hold if SBP [systolic blood pressure] under 110." On 04/06/24, the medication was administered despite the systolic blood pressure being documented as under 110. The need to ensure signed physician's orders were documented in the resident's record for all treatments the facility administered, and all physician's orders were carried out as prescribed, was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings, and no additional information was provided. 4. Resident 6 was admitted to the facility in 09/2023 with diagnoses including generalized anxiety disorder and dementia. Resident 6's MARs, dated 03/01/24 through 04/07/24, and corresponding progress notes and physician's orders were reviewed. The resident had a physician's order for acetaminophen 325 mg (for pain), to be administered two tablets (650 mg) every four hours as needed, "max 2000 mg per 24 hrs [hours]." The resident was administered 2600 mg within a 24 hour period on the following dates: * 03/26/24; * 03/27/24; * 03/29/24; and * 03/31/24. The need to ensure all physician's orders were carried out as prescribed was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings, and no additional information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 4 of 5 sampled residents (#s 3, 4, 5, and 6) whose MARs and physician orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 04/2023 with diagnoses including chronic kidney disease, hypertension, tremor, and weakness. The resident's clinical record was reviewed, including the 03/01/24 through 04/10/24 MARs and physician orders. Interviews were conducted. The most recent signed physician orders were dated 04/05/24 for a hospice "comfort pack." The order noted to discontinue calcium +D, multi-vitamin, and hydrocodone, and to continue "all other previously prescribed medications" including the bowel care regimen. Prior to 04/05/24, the most current signed physician orders were dated 04/18/23, prior to the resident's admission to the facility, with additional orders as follows: * 06/20/23 - Lasix 20 mg tablet (for edema), take 0.5 tablet by mouth daily; * 07/05/23 - Duloxetine 30 mg capsule (an anti-depressant), delayed release, take one capsule every day; * 07/13/23 - Loperamide 2 mg by mouth (an anti-diarrheal) four times a day as needed for loose stool; * 09/18/23 - Furosemide 20 mg tablet (for edema), one tablet by mouth daily; * 11/07/23 - Milk of Magnesia 30 ml (for constipation) as needed four times a day; * 03/30/24 - cefdinir 300 mg capsule (an antibiotic), one capsule daily for five days; and * 03/30/24 - azithromycin 250 mg tablet (an antibiotic), one tablet daily for four days. There were no recent orders for the following medications on the 03/01/24 through 04/10/24 MAR: * Allopurinal 100 mg tab (for gout), 0.5 tablet by mouth every day; * Aspirin ED 81 mg tab (for pain), 1 tablet by mouth every day; * Calcium Carb +D 600 mg/400U tabs (a supplement), one tablet by mouth every day; * Famotidine 10 mg tab (for acid reflux), one tablet by mouth every day; * Gabapentin 300 mg cap (for pain), one capsule by mouth every night at bedtime; * Melatonin 3 mg tab (a sleep aid), one tablet by mouth every night at bedtime; * Multivitamin tab (a supplement), one tablet by mouth every day; * Polyethylene glycol 17 mg pack (for bowel care), dissolve one packet into liquid and drink by mouth every morning; * Compression socks (for edema) on at 0800, off at 2000; * Acetaminophen 325 mg tab (for pain), two tablets (650 mg) by mouth every six hours as needed; and * Hydrocodone/APAP 5-325 mg tab (for pain), one tablet by mouth twice daily as needed. There was no documented evidence the facility had attempted to obtain more recent orders from the resident's physician. On 04/09/24 at 4:23 pm, Staff 5 (Health & Wellness Coordinator/LPN) reported she was unable to locate physician orders more recent than 04/2023. She stated she would request the pharmacy to send her all physician orders for the resident. On 04/10/24 at 4:10 pm, Staff 5 provided physician orders received from the pharmacy for the hospice comfort pack and the seven orders between 06/20/23 and 03/30/24. The need to have current physician orders in the resident's facility record was discussed with Staff 3 (District Director of Clinical Operations/RN) and Staff 4 (District Director of Operations) on 04/11/24. They acknowledged the findings.

1) The medication and treatment orders for Residents 3, 4, 5, and 6 will be reviewed and updated by the community clinical leaders to confirm that the orders are written and followed as prescribed.    2) Community clinical leaders will review new medication and treatment orders to verify that they are written and implemented as prescribed.  Med techs will be re-educated on the community's policies and procedures for transcribing and processing new medication or treatment orders. 3) Community clinical leaders will review physician's orders daily to implement any new orders received.   4) Community clinical leaders will be responsible for the corrections and monitoring.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained, including resident-specific parameters and instructions for PRN medications, for 1 of 4 sampled residents (#5) whose MARs were reviewed. Findings include, but are not limited to: Resident 5 was admitted to the facility in 03/2024 with diagnoses including Type 2 diabetes and left below-the-knee amputation. The resident's 03/07/24 through 04/07/24 progress notes and physician communications, signed physician orders, and MARs were reviewed. The following was identified: a. PRN medications for constipation lacked resident-specific parameters for administration: * Bisacodyl 10 mg suppository; * Milk of magnesia 400 mg/5 ml oral suspension; * Polyethylene glycol 17 gram pack; and * Sodium phosphate enema. b. On 03/09/24, Staff 3 (District Director of Clinical Operations/RN) completed an RN diabetic assessment which included specific parameters related to administrating insulin, including "MTs are to notify MR [sic] and RN of blood sugar below 80 and above 400." This was not included on the MAR until 04/04/24, and there was no documentation that notification occurred when blood sugars tested above 400, which occurred nine times. c. On 03/18/24 Coenzyme Q-10 (supplement) was noted as administered on 03/18/24. On all other dates prior to and after, the medication was documented as not administered due to it not being at the facility. d. The resident had a physician's order for PRN glucose chew, 4 gm, to be used as needed for low blood sugar, without any additional parameters. The need to ensure medication administration records were complete was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings.

1) The MAR for Resident 1 has been reviewed and updated to include resident-specific parameters and instructions for their PRN medications. 2) Community has scheduled a pharmacy audit to review MARS for accuracy and appropriate parameters.  Community will implement directions given from pharmacy audit promptly.  Community clinical leaders will re-educate med techs on PRN medications, resident-specific parameters and instructions. 3) Upon receipt of a new PRN medication order, Community clinical leaders will review the MAR and new PRN medication orders to confirm that resident-specific parameters and instructions are included. 4) The ED and community clinical leaders will be responsible for the corrections and monitoring.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer medications and had more than one resident in a unit were evaluated for safety and a physician's order was in place for the self-administration for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to: Resident 2 moved into the facility in 03/2022 with a diagnosis of  hearing loss. During the acuity interview on 04/08/24, Resident 2 was identified as self-administering his/her medications and also administering medications to Resident 1, who resided in the same apartment with Resident 2. In an interview on 04/09/24, Resident 2 confirmed s/he self-administered his/her medications and administered medications to Resident 1. Resident 2 indicated medications were kept on the kitchen counter, and s/he did not keep medications in a locked container. Review of Resident 2's records revealed there was no current signed physician's order for the resident to self-administer medications, nor was there a quarterly evaluation of the resident's ability to safely self-administer medication, including his/her ability to administer medications to Resident 1. There was no documented evidence the facility had evaluated Resident 1's ability to safely have medication in the unit. The quarterly self-administration evaluation provided to the surveyor had an effective date of 01/11/24; however, was signed and dated by the RN on 04/08/24, the day survey started. The need to ensure residents who self-administered their medications and had more than one resident residing in the unit were evaluated quarterly and had a current physician's order for self-administering was reviewed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/11/24. They acknowledged the findings.

1) An evaluation of Resident 2's ability to self-administer medications as well as administer medications to Resident 1 will be completed and documented in the resident's record.  As appropriate, a physician's order will be obtained to allow Resident 2 to perform such actions.  Community clinical leaders will review any other residents who self-administer to confirm that an assessment and physician's order is present. 2) Community clinical leaders will be re-educated on the requirement to evaluate a resident's ability to self-administer medication and, if appropriate to obtain a physician's order for self-administration by the resident. 3) Self med reviews will be on file during quarterly assessments. 4) Community clinical leaders will be responsible for the correction and monitoring.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medication used to treat resident behaviors had written, resident-specific parameters and non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication for 1 of 3 sampled residents (#5) who had PRN psychotropic medications. Findings include, but are not limited to: Resident 5 was admitted to the facility in 03/2024 with diagnoses including Type 2 diabetes and left below-the-knee amputation. Review of the resident's 03/07/24 through 04/07/24 MARs and current physician orders revealed the following: * An order for trazodone 50 mg, one tablet to be administered at bedtime as needed for sleep related to insomnia; and * The medication was administered 15 times. The MAR lacked resident-specific parameters for staff describing how the resident presented behaviors such as insomnia. There was no documentation of what non-pharmacological interventions were to be attempted prior to administration of the medication. The need to ensure there were resident-specific descriptions of how the resident behaviors presented, and non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication, was discussed with Staff 1 (Acting ED), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/12/24. They acknowledged the findings.

) The MAR for Resident 5 has been reviewed and updated to include resident-specific parameters and instructions for their psychotropic medication. 2) Community clinical leaders will re-educate med techs on the use of non-pharmacological interventions for behavior before administering psychotropic medications and the need for resident-specific parameters and instructions for such medications. 3) Upon receipt of a new psychotropic medication order, Community clinical leaders will review the MAR and new psychotropic medication orders to confirm that non-pharmacological interventions are included as well as resident-specific parameters and instructions. 4) The ED and community clinical leaders will be responsible for the corrections and monitoring.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to: There was no documented evidence the facility was using an ABST that would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents, and included all the required ABST elements. In an interview on 04/10/24, Staff 1 (Acting ED) and Staff 4 (District Director of Operations) acknowledged the facility's ABST failed to separately list all twenty-two required ADL questions for each resident. On 04/12/24, the need to ensure the facility implemented an ABST which included all required elements was reviewed with Staff 1, Staff 3 (District Director of Clinical Operations/RN), and Staff 4. They acknowledged the findings.

1. As we continue to partner with DHS on reviewing our ABST tool, we will continue to staff according to our Brookdale acuity based staffing tool. 2. Our home office team will continue to establish proper communication with DHS regarding The ABST tool and the 22 elements that make up the ABST tool, we will continue to staff at or above staffing levels currently identified in our tool. 3.  This will be evaluated by the Health and Wellness Director/Resident Care Coordinator to ensure that proper staffing levels are scheduled according to the 22 elements to ensure the scheduled and unscheduled needs of the residents are being met. 4. The Executive Director is responsible to ensure that our staffing levels are appropriate as defined by our staffing tool

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to: There was no documented evidence the facility was using an ABST that would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents, and included all the required ABST elements. In an interview on 08/14/24, Staff 1 Staff 4 (District Director of Operations) acknowledged the facility's ABST failed to separately list all twenty-two required ADL questions for each resident. On 08/14/24, the need to ensure the facility implemented an ABST which included all required elements was reviewed with Staff 4. She acknowledged the findings.

1. As we continue to partner with DHS on reviewing our ABST tool, we will continue to staff according to our Brookdale acuity based staffing tool. 2. Our home office team will continue to establish proper communication with DHS regarding The ABST tool and the 22 elements that make up the ABST tool, we will continue to staff at or above staffing levels currently identified in our tool. 3.  This will be evaluated by the Health and Wellness Director/Resident Care Coordinator to ensure that proper staffing levels are scheduled according to the 22 elements to ensure the scheduled and unscheduled needs of the residents are being met. 4. The Executive Director is responsible to ensure that our staffing levels are appropriate as defined by our staffing tool

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code, fire and life safety instruction was provided to staff on alternate months, and that resident evacuation needs were met. The second floor had multiple residents who were unable to walk down the stairs in the event of an evacuation, and no plan was in place on how to assist the residents. This placed the residents at risk and constituted an immediate threat to the residents' health and safety. Findings include, but are not limited to: a. Fire and life safety records dated 10/2023 through 04/2024 were reviewed. The documentation showed no drills were conducted which simulated fires on the second floor, and all drills used the front door as the escape route. Service plans for the two sampled residents, Residents 5 and 6, who lived on the second floor were reviewed for assistance level needed to evacuate the facility. Resident 5 moved into the facility in 03/2024, after having undergone a left below-the-knee amputation, and was wheel-chair bound. In an interview on 04/08/24, s/he stated s/he had not been instructed on fire safety upon moving into the facility and recently felt concerned when a fire alarm went off, as s/he did not know what to do. Resident 5's service plan did not include any information about evacuation ability and/or level of assistance the resident would require. Resident 6 moved into the facility in 09/2023, required a four-wheeled walker to ambulate, and was identified by facility staff as someone who would be unable to ambulate down the stairs independently. During an interview, the resident agreed with this statement. The resident's evaluation, dated 04/02/24, stated evacuation ability as "independent." The service plan from the same date did not include any instructions to staff regarding assisting the resident to evacuate. Multiple staff were interviewed on day and swing shifts. All staff indicated they did not know how they would get residents who could not ambulate independently down the stairs from the second floor to the main level. Staff identified five residents who were wheel-chair bound on the second floor, and up to 19 residents lived on the second floor who would not be able to ambulate down the stairs independently in case of a fire. During interviews on 04/09/24 and 04/10/24, Staff 1 (Acting ED) and Staff 5 (Health and Wellness Coordinate/LPN) stated they were unaware of a current plan for evacuating residents who were unable to ambulate independently from the second floor, but had begun instruction on the evening of 04/09/24. They stated that they were instructing staff that in the case of a fire, to evacuate the most mobile residents first, and any residents who could not be evacuated should wait in their room until the fire department arrived. On 04/10/24, the survey team reviewed with Staff 1 and Staff 4 (District Director of Operations) that staff must provide fire evacuation assistance to residents from the building to a designated point of safety, and could not tell residents to wait in their rooms. They stated they were not aware of any equipment such as transfers blankets in the facility which would assist staff in evacuating residents from the second floor if they were unable to ambulate down the stairs. When asked how many staff were available on each shift to help evacuate residents, Staff 1 and Staff 5 stated they tried to staff a total of three care staff (one MT and two resident assistants) on noc shift, but acknowledged that recently there had only been two staff working during noc shift. This constituted a significant risk to resident health and safety and required an immediate plan of correction to ensure residents on the second floor could be safely and effectively evacuated to the first floor in case of a fire. The facility submitted a plan of correction to the survey team which included: * Evaluating residents for their ability to evacuate and thereby identifying residents who would require assistance; * Instructing residents on the evacuation plan; * Immediately obtaining a mechanical stair climber which could be used to evacuate non-ambulatory residents down the stairs and educating staff on all shifts on correct usage; * Ordering transfer blankets; and * Ensuring no less than three staff were available on all shifts including noc shift. On 04/11/24 at 4:53 pm, the facility submitted the plan of correction and it was approved by the survey team. The immediate jeopardy situation was abated. b. Fire and life safety records, dated 10/2023 through 04/2024, showed fire drill documentation was lacking in the following areas: * Escape route used; * Problems encountered; * Evidence of alternate routes used; * Evacuation time-period needed; and * The number of occupants evacuated. Additionally, the records reviewed did not show fire and life safety training was provided to staff on alternating months from the fire drills. The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from fire and life safety training was discussed with Staff 1, Staff 3 (District Director of Clinical Operations/RN) and Staff 4 on 04/12/24. They acknowledged the findings.

1. Fire and life safety documentation for fire drills will include : * Escape route used; * Problems encountered; * Evidence of alternate routes used; * Evacuation time-period needed; and The number of occupants evacuated. Documentation will demonstrate fire and life safety training is provided to staff on alternating months for the fire drills. 2. Fire Drill log will address each of the above areas specifically for each  fire drill conducted. 3.Fire Drill logs will be reviewed monthly for ongoing compliance. 4. Maintenance Director and Executive Director will monitor monthly.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed about the facility's fire and life safety procedures within 24 hours of admission and re-instructed at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (Acting ED) and Staff 6 (Maintenance Manager) on 04/10/24 and 04/12/24. Staff 6 indicated that he was currently starting to instruct residents upon move-in, but this had not been consistently occurring or documented. He stated they did not currently have a procedure for re-instructing residents annually. The need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and annually as required by the Oregon Fire Code was discussed with Staff 1, Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (District Director of Operations) on 04/10/24 and 04/12/24. They acknowledged the findings, and no additional information was provided.

1. Residents will be inserviced on Fire and LIfe Safety instruction with 24 hours of move in and anually thereafter. 2. New moves in wil be reviewed at Daily Stand Up meeting and Maintenance Director will arrange inservice within 24 hours. Fire and Life Safety inservice will be added to Move in Checklist. Annual inservice will be calendered for scheduled care conference closest to annual inservice date 3. Within 24 hours of move in and annually thereafter with a monthly review to idenitfy resdidents approaching annual inservice date. 4. Maintenance Director, Executive Director, RN, and Business Office Coordinator to monitor.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 04/08/24 through 04/11/24. The exterior sidewalks in the courtyard had multiple drop-offs of up to two inches, measured from the concrete to the ground. These drop-offs created potential hazards for residents. A walkway from the west side of the building to the courtyard had raised areas up to 4.5 inches creating a tripping hazard. On 04/11/24, the need to ensure all exterior pathways and accesses were maintained in good repair was discussed with Staff 1 (Acting ED) and Staff 4 (District Director of Operations). They acknowledged the findings.

1. Concrete on west exterior walkway has been professionally leveled and repaired to eliminate raised area that was tripping hazard. 2. Weekly walk through of exterior areas wil be conducted to identify any new areas of concrete walkways requiring repair/replacement and documented in TELS system. Repairs wil be conducted as needed. 3. Exterior walkways will be inspected weekly. 4. Maintenacne Director and Executive Director will monitor ongoing.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to: Observations of the facility on 04/08/24 through 04/11/24 identified the following areas were in need of cleaning or repair: * Windows and screens throughout the facility had an accumulation of debris, cobwebs, and dead insects; * There were dark spots and stains on the carpets in hallways throughout the residential corridors on the first and second floors; * There was a build-up of a yellowish-white, scaly, thick substance on the side of the industrial washing machine in the dirty utility room; *  A washing machine in the first-floor laundry room used by residents was out of service; * The bathroom flooring in Room 109 was pulling away from the floor behind the toilet; * Exterior entryways and light fixtures had an accumulation of dirt, debris, dead insects, and cobwebs; * Security cameras mounted above the exterior exit doors on the west and east side of the building were inoperable; and * A wooden fence on the east side of the building had a broken latch on the gate which prevented the gate from closing. Interviews during the survey with Staff 6 (Maintenance Manager) and Staff 19 (Laundry Aide) revealed the drain used for the industrial washing machine would often overflow, causing water to flood the utility room. The need to ensure the facility's environment was clean and maintained in good repair was discussed with Staff 1 (Acting ED) and Staff 4 (District Director of Operations) on 04/11/24. They acknowledged the findings.

1. Professional pressure wash of exterior of community to include windows, screens, doorways, and overhangs will be scheduled and completed. Industrial washing machine will be replaced with new high temp machine that has been apprvoed and ordered. Room 109 has had all bathroom flooring replaced. Professional carpet cleaning will be scheduled to address carpet stains in residential hallways on first and second floors.  Diasabled security cameras on exterior doors will be removed. Broken latch on east gate attached to wooden fence will be replaced. 2. Routine maintenance checklist in TELS system wil be utilized to consistently address preventive maintenance for exterior areas and common area carpets. Work orders submitted for intermittent issues will be addressed weekly and as needed. 3. Exterior pressure washing wil be scheduled quarterly and as needed.  Weekly community walk through of common areas and exterior grounds will be completed to identify areas for cleaning/repair. Common area carpet cleaning will be scheduled monthly and as needed. 4.Maintenance Director and Executive Director will monitor ongoing.

Based on observation and interview, it was determined the facility failed to ensure soiled clothing and linens were laundered in a machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant. Findings include, but are not limited to: The facility laundry rooms were observed on 04/09/24. The following was identified: In an interview on 04/09/24, Staff 19 (Laundry Aide) explained the process for laundering soiled linens and clothing. Soiled linens and clothing were brought to the dirty utility room on the first floor, rinsed in the hopper sink, and then placed in the industrial washing machine. Commercial-grade laundry detergent was observed mounted to the wall, which automatically dispensed detergent into the washer. Staff 19 reported she was not sure of the temperature of the rinse cycle in the washing machine or if the detergent contained a disinfectant. During an interview on 04/11/24, Staff 1 (Acting ED), Staff 4 (District Director of Operations), and Staff 6 (Maintenance Manager) were unable to confirm whether there was a chemical disinfectant in the detergent. The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 and Staff 4 on 04/11/24. They acknowledged the findings.

1. New commercial washer approved for purchase to ensure water temps reach disinfectant level of 140 degrees. 2. New commercial washer has been purchased. 3. Water temps will be reviewed weekly by Maintenance Director or designee. 4. Maintenance Director and ED will be responsible for monitoring.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system for security purposes and to alert staff when residents exited the building. Findings include, but are not limited to: The facility was toured on 04/08/24 through 04/11/24. Observations and interviews with staff during the survey confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents exited the building. The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility was discussed with Staff 1 (Acting ED) and Staff 4 (District Director of Operations) on 04/11/24. They acknowledged the findings.

1. Existing exterior door alarms have been activated for exterior courtyard doors and alternate exit doors. Additional alarms will be installed for exit doors at the end of each residential hallway. 2. Staff will be re-educated on community policies regarding door alarms.  Signs will be posted at the exit doors notifying all that the doors are alarmed at all times. 3. Maintenance Director will test alarms weekly and change batteries routinely as needed. 4. Maintenance Director and Executive Director will be responsible for monitoring.

Concerns were identified in the following areas and the facility was provided with technical assistance: H1501: Integrated Settings: Community Life OAR 411-004-0020 (1)(a) The setting is integrated in and supports the same degree of access to the greater community as people not receiving HCBS, including opportunities for individuals enrolled in or utilizing HCBS to: (B) Engage in greater community life.

Concerns were identified in the following areas and the facility was provided with technical assistance: H1503: Integrated Settings: Services OAR 411-004-0020 (1)(a) The setting is integrated in and supports the same degree of access to the greater community as people not receiving HCBS, including opportunities for individuals enrolled in or utilizing HCBS to: Receive services in the greater community.

Concerns were identified in the following areas and the facility was provided with technical assistance: H1512: Optimize Settings: Independence Activities OAR 411-004-0020 (1)(e) The setting optimizes, but does not regiment, individual initiative, autonomy, self-direction, and independence in making life choices including, but not limited to: daily activities, physical environment, and with whom the individual chooses to interact.

Concerns were identified in the following areas and the facility was provided with technical assistance: H1518: Individual Door Locks: Key Access OAR 411-004-0020 (2)(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. Can have an IBL.

Based on interview and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C361.

See correction C361

The findings of the relicensure survey, conducted 04/08/24 through 04/12/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day A situation was identified where there was a failure of the facility to comply with the Department's rules that was likely to cause residents serious harm. An immediate plan of correction was requested in the following area: OAR 411-054-0090 Fire and Life Safety: Drills and Instruction The facility put an immediate plan of correction in place during the survey and the situation was abated.

The findings of the first re-visit to the re-licensure survey of 04/12/24, conducted 08/12/24 through 08/14/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 04/12/24, conducted 04/08/25 through 04/09/25, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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 completed on 03/12/24 from 11 am through 3:30 pm and the following was identified:   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:   * Floors and walls under dish machine; * Floors throughout kitchen; * Walk in cooler floors/corners/edges/walls; * Walls throughout kitchen; * Fans and metal cages of fans; * Reach in coolers and freezers; * Open shelving throughout kitchen; * Interior and exterior of microwave; * Interior and exterior of convection ovens; * Exterior and interior of steamer; * Range top, grill top; * Metal shelves storing pots/pans/dishes; * Knobs of steam table; * Steam table wells; * Cabinet with plate warmer; * Industrial can opener and housing; * Steamer with scale build up and dirty on interior and exterior; * Industrial mixer; * Door thresholds with food debris/splatter; * Interiors and exteriors of stainless steal drawers; * Go racks stored in walk in; * Metal racks in Walk in cooler; * Freezer fan cages; * Outside and handles of trash cans; * Small appliances (blender/robot coupe); * Ice scoop holder; * Window seal and screens: and * Kitchen drains. b. The following areas were in need of repair:   * Hole in wall under prep counter where cutting boards stored; * Three compartment sink faucet with leak; * Spring loaded sprayer broken and sitting at bottom of sink; * Caulking behind hand washing sink and ware washing area with black mold like substance; * Pipe from wall next to large fan with gap needing sealed; and * Sprinkler in walk in cooler leaking. c. Scoops/spoons observed in bulk food containers with handles touching food surfaces. Coffee filters stored uncovered and open to potential contamination. d. Multiple cutting boards and cutting surfaces were found heavily stained and scored. Multiple pans/utensils with damage and wear needing to be replaced. e. Multiple food items found in walk in cooler without proper labels and/or dates as required. Items found open or not sealed appropriately to protect from potential contamination. f. Multiple food packages were found open in dry storage. g. Shell eggs and liquid eggs stored over box of "fresh greens". Cardboard box of food items with visible wet debris. Staff stating sprinkler in walk in leaking. h. Multiple cooking/prep dishes were not stored inverted as required and were observed to have visible debris in them.   i. Large meat roast observed being thawed under cold running water upon entry to kitchen. These roasts were then observed at 12:25 on a large pan on a go rack in the main kitchen. Again at 1:35pm these meat roasts were still observed out of refrigeration on the pan on the go rack. j. Cardboard and recyclables were not stored appropriately and were not separate from food preparation areas. Staff 2 indicated they did not have a good space to store them until taking out to garbage area. k. At 12:05 pm, a staff member entered into kitchen and got ice out of ice machine. The staff member did not wash hands and did not have their hair restrained as required. Staff 2 (Dining Service Coordinator) toured kitchen areas with surveyor and acknowledged identified areas needing attention. At approximately 3:00 pm, surveyor reviewed above areas with staff 1 (Administrator), who acknowledged the findings.

-DSC trained on Menu Manager by Dining Pro-Temp Specialist. Menu Manager ensures three daily nutritious, palatable meals with sncaks available severn days a week.  Snacks have been scheduled to be provided at 10:00 am, 3:00 pm & 6:00pm for Claire Bridge. -DSC conducted Modified special diets training on 4/2/24. -DSC will conduct Menu Chat 2x a month (Bi-Weekly) with all residents encouraged to attend in support of developing menus. DSC will have menus completed each Saturday for the following week. Week at a glance will be posted in the dining room allowing residents to view. DSC & Pro-Temp have menu in community matching menu on Community Website. Should a change be made to an existing menu, the DSC and or Cook on shift will update menu slips prior to the residents arrival to the dining room for the specified meal having changes. Dining Servers will have a pre-shift meeting conducted prior to each meal. Any changes made to the menu will be discussed during pre-shift ensuring servers know what is being served. A sample plate for both AL and Clare Bridge will be provided for residents to see the presentation of entrees being offered. March 22, 2024- Restaurant Exhaust completed cleaning of  all kitchen surfaces including: ceilings, kitchen equipt., tables, light lenses. All line equipment under the hood: Ovens, stoves, flattop griddles, etc..All Light lenses and bulb covers (21), and all kitchen tables, shelves, carts and appliance surfaces. April 2, 2024- Summit Cleaning and Restoration will be completing   oDeep Cleaning of all FRP Wall Panels oDeep Cleaning of all Tiled Flooring in Kitchen, Dish Room, & Hallway oMildew Removal & Treatment around Dishpit oDeep Cleaning of all Tile Flooring in Kitchen, Dish Room, & Freezer. -DSC implemented cleaning schedule for all servers and cooks along with cleaning schedule and expectations from Brookdale Cleaning Schedule. Expectations will posted on bulletin board for all to see and know the expectations on a daily basis. DSC responsible for reviewing task sheets and following up on completed tasks to ensure tasks completed correctly and efficiently. Task lists include but not limited to: * Interior and exterior of microwave; * Interior and exterior of convection ovens; * Exterior and interior of steamer; * Range top, grill top; * Metal shelves storing pots/pans/dishes; * Knobs of steam table; Steam table wells; * Industrial can opener and housing; * Cleaning of Steamer removing scale build up on interior and exterior will be completed after each meal service; * Cleaning of Industrial mixer after each use; * Cleaning of Door thresholds with any food debris/splatter; * Interiors and exteriors of stainless steal drawers; *Pressure washing weekly and daily Cleaning of trash cans on the outside including handles * Freezer and fan cages are working and are checked every 4 hours. * Window seals cleaned and screens pressure washed * Ice scooper container on task list to be washed each day along with only on scope placed in container. *Open shelving holding dishes will have doors installed protecting dishes from dust and food debris. Cabinet with plate warmer has been cleaned and will have door installed closing up the open area. A vent will be installed allowing for proper airflow. * Hole in wall under prep counter where cutting boards stored repaired by Maintenance Director. Metal plate placed on back of wall preventing cutting boards from hitting wall resulting in holes. * Roto Rooter has ordered drains for three compartment sink Roto Rooter will also be capping off overflow holes; Maintenance Director will be replacing faucet ring stopping leak. * Spring loaded sprayer replaced with new sprayer allowing sprayer to dangle above the bottom of the sink; * Maintenance Director will be completing new Caulking behind hand washing sink upon completion of Summit wall and floor cleaning. *Ware washing area with black mold like substance will be cleaned and treated along with new caulking an selant applied. Summit Restortation will complete cleaning and Maintenance Director will complete new caulking and sealant. * Pipe from wall next to large fan with gap will be filled with Fire Caulking by the Maintenance Director * Sprinkler in walk in cooler leaking will be repaired by Harvey & Price on 4/3/24. *New containers ordered with holder for Scoops/spoons for bulk food containers to prevent handles touching food and/or surfaces. *Coffee filters stored in a covered container to prevent potential contamination. *Cutting boards have all been replaced with new cutting boards. *Replacement Pans/utensils ordered on 3/31/2024. *DSC and Pro-Temp completed trainings with cooks and servers on the proper labeling protocols. * DSC ordered new food containers to store opened items ensuring and and all open items are sealed appropriately to protect from potential contamination. * DSC and Pro-Temp completed training on FIFO order along with posting Food Storage Chart on front of fridge door. * DSC ordered new storage containers with scoop holders to house dry ingredients stored in dry storage. * Walk-in fridge has been organized by DSC and Pro-Temp following Crandall guidelines. Shell eggs and liquid eggs along with all dairy items are stored in the back of the walk-in fridge (coldest section) from top shelf to bottom shelf having no non-dairy items stored above or below dairy products. *DSC and Pro-Temp have reorganized all cooking/prep dishes which are now stored inverted as required preventing any debris build up. *DSC and Pro-Temp completed training on proper thawing of frozen meat products on 4/2/24. *Cardboard broken down and taken out to recycling thoughtout the day rather than piling up in the back of the kitchen. This task is assigned and is being completed by the Dish Aid on shift with the DSC following up to ensure this task is being complete and not cardboard is piling up. * ALL Associates have received specific instruction and training on applying hair nets upon entering the kitchen and washing hands immediately after placing hair net on head.

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 ALF kitchen was completed on 05/13/24 from 10:15 am through 12:45 pm and the following was identified:     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:   * Ceiling vent near prep area * Floors throughout kitchen; * Walls throughout kitchen; * Fans and metal cages of fan by serving area; * Open shelving throughout kitchen; * Interior and exterior of microwave; * Interior and exterior of convection ovens; * Exterior and interior of steamer; * Range top, grill top; * Metal shelves storing pots/pans/dishes; * Steam table wells; * Industrial can opener housing; * Steamer interior and exterior; * Industrial mixer; * Door thresholds with food debris/splatter; * Interiors and exteriors of stainless steel drawers; * Window seal and screens; and * Kitchen drains. b. The following areas were in need of repair:   * Areas by electrical conduit/pipes with gaps. c. Scoops were observed in bulk food containers with handles touching food surfaces. d. Multiple food items were observed in walk-in cooler without proper labels and/or dates as required. Container of cut tomatoes was found stored in walk-in cooler. It was dated 04/30/24 multiple days past seven days that's allowed per rule. e. Multiple food packages were found opened in dry storage without open dates. f. Thawing meats were not stored correctly according to appropriate cook to temps to prevent potential cross contamination. Whole pork roasts were noted to be stored directly under ground meat products. Staff 2 (Dining Service Coordinator) toured kitchen areas and acknowledged areas in need of correction.  At approximately 12:30 pm, surveyors reviewed above areas with Staff 1 (Interim Executive Director) and Staff 3 (Memory Care Administrator), who acknowledged the findings.

- Floors throughout the kitchen cleaned and added to daily checklist -Walls throughout the kitchen cleaned and added to daily checklist Open shelving throughout kitchen cleaned and added to daily checklist Interior and exterior of microwave cleaned and added to daily checklist Interior and exterior of convection ovens cleaned and added to daily checklist Exterior and interior of steamer cleaned and added to daily checklist Range top, grill top cleaned and added to daily checklist Metal shelves storing pots/pans/dishes cleaned and added to daily checklist Steam table wells cleaned and added to daily checklist Industrial can opener housing cleaned and added to weekly checklist Industrial mixer cleaned and added to daily checklist Door threshholds with food debris/splatter cleaned and added to daily checklist Interiors and exteriors of stainless steel drawers cleaned and added to weekly checklist Window seal and screens cleaned and added to weekly checklist Kitchen Drains cleaned and added to weekly checklist -Areas with electrical conduit pipes that have gaps will be filled in by Maintenance staff by 5/31/24 Proper labeling of all food items will be done by kitchen staff and be monitored daily Dry storage items that are opened will be labeled with open dates and monitored daily Storage scoops will be put up and not sitting in food bins and monitored daily Thawing meats will be stored according to the food storage heirarchy and monitored daily **Staff will be retrained on the following: -Proper storage of scoops in bulk food containers -Proper labeling and storage of food in both dry storage and in refrigerators and freezers -Food storage heirarchy All Items will be monitoried by the ED and Dining Services Manager.

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 ALF kitchen was completed on 07/25/24 from 12:00 pm through 1:45 pm and the following was identified:     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:   * Floors throughout kitchen; * Fans and cages in Walk in cooler; * Floors in walk in cooler; * Open shelving throughout kitchen; * Interior and exterior of convection ovens; * Exterior and interior of steamer; * Metal shelves storing pots/pans/dishes; * Baking "go" racks; * Number 10 can storage racks; and * Kitchen drains. b. Scoops were observed in bulk food containers with handles touching food surfaces. c. Box of frozen hamburger patties were found open and uncovered in the walk in cooler. On 07/25/24, Staff 2 (Dining Service Coordinator) toured the kitchen with the surveyor and acknowledged the findings.  At approximately 1:30 pm, the surveyor reviewed the above areas with Staff 1 (Interim Executive Director) and Staff 3 (Memory Care Administrator), who acknowledged the findings.

1. Executive Director and Dining Services coordinator will ensure plan of correction is followed and compliance maintained. 2.  Executive Director and Dining Serivces Coordinator will audit areas of focus as outlined in plan of correction, inservice staff as needed on kitchen cleanliness checklists, and inservice staff on proper food storage. 3. Areas of correction wil be audited weekly and as needed 4. Eecutive Director and dining Services Coordinator are responsible for monitoring and ongoing compliance.

Based on record review and interview, it was determined the facility failed to ensure 4 of 9 sampled staff (#2, 3, 4, and 5) who prepared food had active food handlers certificates. Findings include, but are not limited to: On 03/12/24 employee records were requested and reviewed to ensure staff had active food handlers cards on file. Staff 2 (Dining Services Coordinator) and Staff 3 (Cook) whose food cards could not be located.  In addition, Staff 4 and Staff 5 (Resident Assistants) did not have active food handlers cards. Staff 1 (Executive Director) acknowledged the need for food handler cards for these individuals.

C370: DSC has completed Serve Safe testing and has been issued her Serve Safe Certification as of 4.1.24. Staff 3 (cook)- will have Food Handler card by 4.3.24. Additional Cook will have food handler card by 4.4.24. Business Office Coordinator has copies of all associates food handlers cards on file in Business Office

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

Refer to C 240.

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

1. Food spills,splatters,loose food, trash debris, and dust/dirt floors throughout kitchen, including floors in walk in cooler and ares under open shelving will be swept and mopped twice daily. Baking "go" racks, Number 10 storage racks, and metal shelves storing pots/pans/dishes will be pressured washed by 8/14/2024. Interior and exterior of convection ovens will be cleaned by 8/12/2024. Exterior and interior of steamer has been cleaned as of 8/4/2024. Kitchen drains have been cleaned as of 8/4/2024. Fans and cages in walk in will be cleaned as 8/12/2024. Scoops for bulk food storage have been removed from bins and signage posted for staff reference on preventing handles from touching food as of 8/8/2024. 2.  Executive Director and Dining Services Coordinator will audit areas of focus as outlined in plan of correction, inservice staff as needed on daily kitchen cleanliness checklists, use and storage of bulk food scoops. and inservice staff on proper food storage. 3. Areas of correction wil be audited weekly and as needed. 4. Executive Director and Dining Services Coordinator are responsible for monitoring and ongoing compliance.

The findings of the kitchen inspection, conducted 3/12/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 03/12/24, conducted 05/13/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the secod revisit to the kitchen inspection of 03/12/24, conducted 07/25/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the third revisit to the kitchen inspection of 03/12/24, conducted 09/19/24 through 09/20/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview, and record review, during a site visit conducted on 12/04/23, it was confirmed the facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week. Findings include but are not limited to: On 12/04/23, CS observed the following, ·Not all menu options listed on the menu were made or offered. ·No snacks available to residents. ·A sampled plate provided at 12:50 pm consisted of the following, oMeatloaf-dry, greasy, and lukewarm. oHaddock- flavorless with nothing served to accompany it, such as tartar sauce or lemon. oRisotto- hot and flavored well. oPotatoes- steamed with no flavor. oMushrooms and broccoli- cooked evenly. During an interview on 12/04/23 Staff 3 (Dining Service Coordinator) stated the following, ·"I did not have a menu chat meeting last month because I was tired of being criticized."   ·"Providing snacks has been an issue we have not been addressing." During lunch service on 12/04/23 CS interviewed residents who stated the following, ·"Meatloaf was dry, greasy, and had no flavor." ·"A lot of items listed on the menu are not available." ·"We are often served cold food." A review of the weekly menu of 12/03/23 through 12/09/23 stated the following menu options were available on 12/04/23: ·Zesty stewed tomatoes. ·Kale salad and mixed greens with pear and pecans. ·Pear crisp, sugar free vanilla pudding, honey cake, and sugar free blueberry cake. ·Baked haddock and meatloaf. ·Risotto and buttered potatoes. ·Steamed beets, mushrooms, and bell peppers. ·The "mid evening snack": fig newton bars. A review of the resident comment and suggestion cards revealed several comments of the meals having been cold. The food temperature logs indicated the kitchen staff had not been consistent with taking the temperature for every meal. The menu chat meeting notes from 9/13/23 and 10/11/23 indicated the following complaints, ·"Snacks and coffee should be out daily." ·"Room trays missing desserts."   ·"Meat is always tough or overcooked." It was confirmed the facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week. On 12/04/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The dining service coordinator will continue to have monthly meetings with residents and has comment card for daily feedback. S/he will continue to share resident feedback with staff to improve the food quality. The ED and dining service coordinator will ensure snacks are ordered and put out to be available to residents and will monitor the snack bar moving forward.

Based on observation, interview, and record review, conducted during a site visit on 12/04/23, it was confirmed the facility failed to provide a daily program of social and recreational activities. Findings include, but are not limited to: The facility's "calendar changes and added activities" flyer indicated a Christmas tree decorating activity was to take place on Sunday, 12/03/23, at 1:00 pm. The facility's "Daily events" calendar indicated the activity was to take place on Monday 12/04/23 at 2:00 pm. On 12/04/23, CS observed the Christmas tree decorating activity scheduled at 2:00 pm. Staff 4 (Activities Director) did not show up until 2:15 pm and provided no direction to the residents who had shown up. At 2:45 pm Resident 6 asked the receptionist what was going on. The front deck personal stated Staff 4 was looking for the lights for the tree. Staff 4 was not prepared for the scheduled activity and did not start the Christmas tree decorating until 3:00 pm. During separate interviews on 12/04/23, Residents 1, 2, 4, and 6 stated the activities on the calendar often do not happen. Resident 2 stated, "The facility was without a bus driver for months so none of the outings that were scheduled happened." Resident 4 stated "None of the activities are planned around residents who are in wheelchairs." During an interview on 12/04/23, Staff 2 (Dining Service Coordinator) stated, "There is an activities calendar, however, it is not followed and often the activities are canceled. On Sundays when management is not here all the activities are canceled." On 12/04/23, the findings were reviewed with and acknowledged by Staff 1 (Executive Director). It was determined the facility failed to provide a daily program of social and recreational activities. Verbal plan of correction: Staff 1 will meet with the activities director to ensure s/he is prepared for the planned activities. The activities director will meet with residents to determine the types if activities they would prefer to see on the calendar.

Based on interview and record review, during a site visit conducted on 12/04/23, it was determined the facility failed to ensure a resident monitoring and reporting system is implemented 24-hours a day for 1 of 1 sampled resident (#1). Findings include, but not limited to: During an interview on 12/04/23, Staff 1 (ED) indicated the facility was to monitor Resident 3's weight monthly. On 11/20/23 the facility changed Resident 3's weigh ins from monthly to weekly. A review of Resident 3's weights and vitals summary indicated the facility had not monitored Resident 3's weight between 06/04/23 through 10/30/23. A review of Resident 3's July, August, and September 2023 MARs indicated the following, ·On 07/07/23, Monthly weight unable to get, will get tomorrow. ·On 08/07/23, stated "This MT ran out of time, resident will be put on the need to get vitals list."   ·On 09/07/23 resident had refused monthly weigh in. It was determined the facility failed to ensure a resident monitoring and reporting system is implemented 24-hours a day. On 12/04/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The facility had switched from monthly to weekly weight ins.

Based on observation and interview, conducted during a site visit on 12/04/23, it was confirmed the facility failed to ensure the staff person who administered the medication visually observed the resident take the medication for 2 of 2 sampled residents (#1 and 2). Findings include, but are not limited to: On 12/04/23, Resident 2 provided CS with individual packets of medication s/he had found throughout the facility. The medication consisted of Zolpidem for insomnia, Losartan for hypertension, Amlodipine for hypertension, and Tylenol. During an interview on 12/04/23, Resident 2 indicated s/he had found multiple medications on the floors in the hallways and common areas. S/he had brought the concern to management on separate occasions. A review of an email correspondence from Staff 7 (LPN) listed Resident 1 and Resident 2's self- administered medication which indicated neither resident was prescribed any of the listed above medication. It was confirmed the facility failed to ensure the staff person who administered the medication visually observed the resident take the medication. On 12/04/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: None was provided.

Based on interview and record review, during a site visit conducted on 08/22/23, it was confirmed the facility failed to terminate employee immediately once a failed background check was received. Findings include, but are not limited to: In an interview on 08/22/23, Staff 1 (Executive Director) stated, "The staff member in question was hired back in January by an old ED. The company's background checks get ran twice. On the first, the employee came back as passed and was hired. On the second run the staff did not pass the background check. The facility did not immediately fire the employee which is where we went wrong. Once I was made aware, the staff member was terminated on 07/18/23." A review of Staff 6's background check and termination paperwork showed the following: ·On 01/03/23, Staff 6 passed the first round of the background check. ·On 01/20/23, the background check unit sent a letter to the facility which stated, the decision was effective on the date of the notice. The subject individual may not hold the position listed above effective immediately. The staff member must be terminated or removed from your agency immediately. ·On 07/18/23, Staff 6 was issued a termination of employment due to the denied background check. It was confirmed the facility failed to terminate employee immediately once a failed background check was received. On 08/22/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The facility will follow their policy and procedure for background checks with employees. They demonstrated this a couple weeks ago where they had a separate employee not pass the second round of background checks and that staff was terminated from employment immediately.

The findings of the on-site investigation, conducted 08/22/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse Notes on Abbreviations: "The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. "Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate. "Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. "If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

The findings of the on-site investigation conducted 06/14/2023 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:                        Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include: During an interview on 03/28/2023, Staff #1 (S1) stated that their ABST is the same tool they have been using. During an unannounced site visit on 03/28/2023, Compliance Specialist (CS) observed 3 Caregivers (CG) and 2 Med Tech (MT) working during the day shift. A review of the facility posted staffing plan and the facility ' s Acuity Based Staffing Tool (ABST) indicate that the facility ABST tool does not have all 22 activities of daily living (ADL ' s) outlined individually for each resident and an amount of staff time needed to provide care. The facility ' s ABST had multiple ADLs grouped together in subcategories. For example, there is a section for dressing and grooming that has personal hygiene, assistance with communication, hearing devices, vision and speech categorized together. The posted staffing plan and the ABST stated that on day shift the facility needs 1 MT and 3CG are required. On 03/28/2023, these findings were reviewed and acknowledged by S1.

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 03/28/2023.  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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: 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 03/28/2023.  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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: 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 02/09/2023.  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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview, observation, and record review it was confirmed the facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week. Findings include: During separate interviews on 02/08/2023, Staff #1-2 (S1 and S2) stated that there have been concerns revolving the quality and palatability of the food. A cooperate food consultant is onsite and will be providing additional consulting to help elevate the kitchens performance. S2 stated that the kitchen has undergoing many in-service trainings, there will be one for the proper handwashing techniques. Resident #1-3 (R1, R2, R3) all state concerns around the meals being nutritious, palatable, or available. The following was stated:    " The beef in the beef tips today was tuff and hard to chew.   " The facility has gone days without butters, creamers, and sugars on the tables.   " There was a period where there was no orange juice for weeks.   " Many times, we do not get what we have ordered " Multiple meals have been skipped during a covid lockdown there were many days and meals that were not provided unless I called staff and told them I did not receive a meal.   " The kitchen runs out of food. " Poached eggs/ breakfast has been a huge issue for months. During an unannounced site visit on 02/08/2023, Compliance Specialist (CS) observed,    " The kitchen starting to run out of enough pie portions and cut the portions to slivers to ensure everyone got a piece.   " Many residents taking the beef out of their dish and setting it to the side because they couldn't chew the meat. A review of resident council notes from January-February 2023, pictures provided by R2, and an in-service conducted on 2/7/2023 for the kitchens understanding of labeling products and first in, first out. On 02/08/2023, these findings were reviewed and acknowledged by S1. Plan of Correction: The facility promoted a new dining coordinator and has a cooperate consultant working with the kitchen to ensure better performance and quality of food.

Based on interview and record review it was confirmed that the facility ' s service plans are not getting updated quarterly. Findings include: During separate interviews on 02/08/2023, Staff #1 (S1) stated there are several residents service plans that have not been updated quarterly. There is a team of staff from a sister facility currently working on getting the service plans updated. A review of the Service Plan binders indicates they have multiple service plans not updated quarterly. On 02/08/2023, these findings were reviewed and acknowledged by S1. Plan of Correction: The facility is currently working on getting all residents service plans updated. S1 states they will ensure quarterly updates moving forward.

Based on interview and observation it was confirmed the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. Findings include: During separate interviews on 02/08/2023, Resident #1-3 (R1, R2 and R3) stated that the dining room has been dirty for some time, and no one cleans it. R2 stated that housekeeping has been short for weeks and their room had not been cleaned for weeks due to not having enough staff to provide services. R2 stated that they have had to vacuum their own room, wash their linens, and make their own bed. Staff #3 (S3) stated there the facility was short staffed because one caregiver went home. On shift that day was 2 Med Techs (MT) and 2 Caregivers (CG). During an unannounced site visit on 02/08/2023, Compliance Specialist (CS) observed 2 MT and 2 CG working. No documents were provided for site visit. On 02/08/2023, these findings were reviewed and acknowledged by S1. Plan of Correction: No plan was provided by S1.

Based on interview and record review it was confirmed the facility failed to provide records to the Department upon request. Findings include: Compliance Specialist (CS) requested documentation from the facility for an investigation conducted on 2/8/2023 and did not receive them. Reviewed email request dated 2/10/2023 following up on the request for documentation still needed to Staff #1 (S1). The facility did not provide the documentation requested. On 02/16/2023 CS informed S1 about documentation not being provided upon request. Plan Of Correction: Per S1 email on 02/17/2023 in the future, they will be responding to requests for documentation within 48 hours.

Based on interview and observation it was confirmed the facility failed to keep all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. Findings include: During separate interviews on 02/08/2023, Staff #1 (S1) stated no action has been taken to repair main fireplace other than putting the out of order sign up. S1 stated that the facility is only budgeted for 10 hours of housekeeping per day. Resident #2 (R2) stated that housekeeping has been short for weeks and their room had not been cleaned for weeks due to not having enough staff to provide services. R2 stated that they have had to vacuum their own room, wash their linens, and make their own bed. During an unannounced site visit on 02/08/2023, Compliance Specialist (CS) observed,    " The main fireplace to be not working with an out of order sign on it. " The dining room tables and chairs to be sticky and dusty. " Buckets of rock salt around the facility exit doors.   On 02/08/2023, these findings were reviewed and acknowledged by S1. Plan of Correction: On 2/9/2023 the facility's maintenance director placed a call out to Albany Stove to have the fireplace repaired.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/08/2023.  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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview and observation it was confirmed that the facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week. Findings include: During separate interviews on 11/23/2022 with Staff #2, #5, #6 and #7 (S2, S5, S6, and S7) all stated that the lunch meal service should start delivering food at 12:00pm. S6 stated that breakfast service took 3 hours to deliver. Compliance Specialist (CS) walked into the kitchen and S7 stated the following,    -That as of 12:20pm there hasn't been any food taken out due to staffing issues and that it would still be another 30 minutes before any food is sent out.   -The last cart of deliveries was pushed out at 1:45pm. -The kitchen has been hectic the whole week and normally the kitchen staff label and date the food but due to the time constraints they haven ' t been able to accomplish the task.   -The food delivery had come in a couple days before, but the kitchen staff have not had the time to put any of the order away.    Resident #5 (R5) stated portions of food are small and cold. R5 stated that one day for breakfast the kitchen served rice and toast. During an unannounced site visit on 11/23/2022, Compliance Specialist (CS) observed:   -Meal service to be 2 hours late with the last meal being delivered at 2:00pm. -Multiple boxes stacked up on prep station.   -Boxes of food in the refrigerator, freezer and dry storage on the floor blocking the pathway. -Multiple food in the refrigerator to be not labeled or dated with expiration dates being unknown. -Molded cheese uncovered in the refrigerator.   -Food container bins uncovered.   -A bag of raw chicken sitting out on the counter. On 11/29/2022, these findings were reviewed and acknowledged by Staff #1 (S1). Plan of Correction: S1 stated the order has been put away and the kitchen will audit the fridge and get all the food out that is out of date or not labeled. S1 said training to staff would occur once CS left for their understanding on how to properly label and date food. The facility is trying to fill the gap with other staff members (Dining manager and other cooks that do not work 40hrs to serve) for meal service to provide faster times for meals. S1 stated that the facility started this on 11/30/2022.

Based on interview and observation it was confirmed the facility failed to provide or arrange for transportation for medical and social purposes. Findings include: During separate interviews on 12/6/2022, Staff #1 (S1) and Resident #5 (R5) are quoted saying the following:   -The facility is currently without a bus driver. One was hired but didn't pass their safety exam. -The bus was in the shop due to vandalism. -The facility closed all transportation and group activities due to a Gastrointestinal Infection (GI) outbreak for two weeks. -The bus is not on a regular schedule and do not go out every week.   -The bus rarely moves. During an unannounced site visit on 12/6/2022, Compliance Specialist (CS) observed the bus parked and not being used. On 12/6/2022, these findings were reviewed with and acknowledged by S1. Plan of Correction: S1 stated that the facility will work on keeping vandals from stealing gas, putting a policy in place to ban cutting bus gas lines from their bus, and work on keeping gastro virus issues out of the community.

Based on interview and observation it was confirmed that the facility failure to have awake qualified direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents. Findings include: During an onsite interview on 11/23/2022, Staff #2-3 (S2 and S3) stated that they were sharing one Med Techs duties for the day. Staff #5-7 (S5, S6 and S7) stated that the meals are being delivered late due to shortage of staff. S7 stated that they were short in the kitchen and with servers. S6 stated that because of needing to deliver all meals to the residents ' rooms when they are short servers there are days when at least one Caregiver (CG) must help serve meals. During an unannounced site visit on 11/23/2022, Compliance Specialist (CS) observed    " The lunch meal service to take over 2 hours to deliver.   " Resident #3 (R3) push their call light for assistance, it took staff 17 minutes to respond.   " Garbage cans in common area laundry rooms overflowing.   " Multiple boxes scattered the hallways. A review of the resident council notes dated 10/12/2022 states complaints about how the call light response times take too long when residents need help. On 11/29/2022, these findings were reviewed and acknowledged by S1. Plan of Correction: S1 stated the facility will increase training for call lights, they are currently hiring, and are trying to fill the gap with other staff members (Dining manager and other cooks that do not work 40hrs to serve) for meal service to provide faster times for meals. S1 stated that the facility started this on 11/30/2022.

Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include: During an interview on 11/23/2022, Witness #1 (W1) stated    -Resident #3 (R3) had not received their shower in 4 days.   -No staff members follow through to ensure all services are completed. -Staffing has been so bad.   -Sometimes staff takes a long time to respond to call lights. During an unannounced site visit on 11/23/2022, Compliance Specialist (CS) observed 4 Caregivers (CG) and 2 Med Tech (MT) working during the day shift. A review of the facility posted staffing plan and the facility's Acuity Based Staffing Tool (ABST) indicated that the facility ABST tool does not have all 22 activities of daily living (ADL's) outlined individually for each resident and an amount of staff time needed to provide care. The facility's ABST had multiple ADLs grouped together in subcategories. For example, there is a section for dressing and grooming that has personal hygiene, assistance with communication, hearing devices, vision and speech categorized together. The posted staffing plan and the ABST stated that on day shift the facility needs 1 MT and 3CG are required. On 11/29/2022, these findings were reviewed and acknowledged by S1.

Based on interview and observation it was confirmed that the facility failed to keep all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. Findings include: During separate interviews on 11/23/2022, Staff #1, #3, #5 and #6 (S1, S3, S5 and S6) all stated that the facility used to use pagers to inform staff of residents call lights. S3 stated that the pagers haven ' t been working for a while which is why S1 bought them walkie talkies to communicate with the receptionist for which residents need assistance. S6 stated that they cannot hear well on the walkie talkies and some Caregivers (CG) don ' t use their walkie talkies. S1 stated that it is company policy to have pagers for call lights. S6 stated that the garbage bins in the laundry rooms have been full all day. During an unannounced site visit on 11/23/2022, Compliance Specialist (CS) observed:   -S6's walkie talkie was not on, making it unable for S6 to hear receptionist when residents called for assistance. -The front desk call light panel to have all residents' pendants to state they were running low battery. -Every laundry room of the facility to have the garbage's full and overflowing. -In multiple hallways there to be boxes stacked up. On 11/29/2022, these findings were reviewed and acknowledged by S1. Plan of Correction: S1 will be ordering more walkie talkies and will have an in-service training for reminding staff to carry their pagers/ walkie talkies. S1 stated that they are starting to conduct this change on 11/30/2022. S1 stated on 11/29/2022 that the trash has been taken out and the facility will ensure that they stay empty. S1 stated that the boxes in the facility have been moved to their appropriate places and are out of the hallways.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 11/23/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: 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 11/02/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: 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 8/31/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview and observation it was confirmed the facility failed to provide household services. Findings include: During onsite interview on 8/31/2022 with Resident #1 (R1) they stated they should be getting housekeeping services every Friday, however, the facility has gone a month without housekeeping services because there wasn ' t anyone doing that job. R1 stated that as of this week the facility has hired a housekeeper. During onsite interview on 8/31/2022 with Staff #1 (S1) stated they recently hired a housekeeper and have switched washing linens back to housekeeping. S1 stated that there was a 3-week time where there was no housekeeper and services were missed. S1 also stated that the facility maintenance personal tried to do some cleaning during the absences of a housekeeper. Staff #4 (S4) stated that showers regularly get missed and room tidies do not get done. During site visit on 8/31/2022 Compliance Specialist (CS) observed two rooms that looked dirty and to have debris on the ground looking like the room had not been swept or vacuumed for a long period of time. CS observed multiple dirty dishes outside residents '  apartments. Verbal Plan of Correction: The facility has hired a new housekeeper and will allow for the cleaning schedules to go back to the original days and all tasks will be provided.

Based on interview, observation, and record review, it was confirmed the facility does not have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include: Record review for site visit on 8/31/2022 of the staff schedule for August 2022, timecards for August 15th-16th, the posted staffing plan and call light logs from 8/22/2022-8/26/2022. Review of the call light logs reveal 169 times where the call lights exceed a 16-minute response time. Out of the 169 times 10 of them exceeded an hour with the longest response time being 1:58:42 wait time. Review of the staff schedule shows multiple days where they were understaffed. Compliance Specialist (CS) observed 2 caregivers (CG) and 2 med aides (MA) to be on duty during site visit on 8/31/2022, which does not reflect the posted staffing plan or the ODHS ABST. During separate onsite interviews on 8/31/2022, Staff #1 (S1) stated that there was a 3-week time where there was no housekeeper and services were missed. Staff #4 (S4) stated that showers regularly get missed and room tidies do not get done. S4 stated that there was a day in the beginning of the month were there was only one CG working who felt overwhelmed. Resident #2 (R2) stated it can take over 20 minutes to respond to call lights. Verbal Plan of Correction: S1 and S2 have hired a few open positions and will continue to hire/train staff members and are working on their turnover.

Based on interview, observation, and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:   Interview with Staff #1(S1) and Staff #2 (S2) on 08/31/2022 stated the facility is using their own ABST.  S2 stated they could provide print outs of the ABST including sample residents showing the 22 ADLs used.  Two email attempts made to S2 on 09/06/2022 for documentation to be provided no later than end of day 09/06/2022.  Documentation of the ABST has not been provided as of 09/09/2022.

Based on interview and observation it was confirmed that the facility failed to keep all interior materials and surfaces clean. Findings include: During onsite interview on 8/31/2022 with Resident #1 (R1) they stated they should be getting housekeeping services every Friday, however, the facility has gone a month without housekeeping services because there wasn ' t anyone doing that job. R1 stated that as of this week the facility has hired a housekeeper. During onsite interview on 8/31/2022 with Staff #1 (S1) they stated that there was a 3-week time where there was no housekeeper and services were missed. S1 also stated that the facility maintenance personal tried to do some cleaning during the absences of a housekeeper. Staff #4 (S4) stated that showers regularly get missed and room tidies do not get done. During site visit on 8/31/2022 Compliance Specialist (CS) observed two rooms that looked dirty and to have debris on the ground looking like the room had not been swept or vacuumed for a long period of time. CS observed multiple dirty dishes outside residents '  apartments. Verbal Plan of Correction: The facility has hired a new housekeeper and will allow for the cleaning schedules to go back to the original days and all tasks will be provided.

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 8/31/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety or welfare of residents. Findings include, but are not limited to: Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room. During observations of the ALF main kitchen on 08/11/22 between 11:00 am and 3:45 pm, multiple kitchen and serving staff were observed not wearing masks properly, exposing their noses and mouths. The need for the facility to ensure all staff consistently follow current masking requirements was reviewed on 08/11/22 at 2:30 pm with Staff 2 (Dining Services Coordinator) and with Staff 1 (Executive Director) at 2:45 pm. They acknowledged the findings.

1) Kitchen staff have been in-serviced and re-trained to wear their masks and keep them pulled up while in the community 2) Dining Service Director will hold kitchen staff accountable to keep their masks on and pulled up while in the community. 3) Daily 4) Dining Services Manager. Executive Director when the Dining Services Manager is not on duty.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, food was prepared properly and surfaces were sanitized, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the ALF main kitchen, food storage areas, food preparation, and food service on 08/11/22 revealed: * The following areas needed cleaning or repair:   - The walls and ceiling of the janitor closet had been removed, exposing pipes, bare wood and metal wall studs;   - There was a large area of floor under the three-compartment sink where tiles had been removed and covered with plywood;   - There was black mold on the wall above the warewashing wash area; and   - There were pieces of old food floating in the water of the steam table troughs.    * Splatters, spills, drips or debris were observed on:   - Floors throughout the kitchen, walk-in refrigerator and walk-in freezer;   - Multiple floor drains;   - The tops of the bread oven and steamer;   - Lower shelves under the steamer, steam table and rear prep counter where cutting boards were stored;   - Wire storage racks in the walk-in refrigerator;   - Steel and plastic serving carts;   - The interior of the microwave oven;   - The can opener blade;   - Multiple blenders and food processors;   - The meat slicer; and   - A ceiling vent over the janitor's closet and the grates of the fans in the walk-in refrigerator. * Plastic bins of oat flakes in the dry storage room were uncovered and oats had been spilled on lower shelves and the floor. * Desserts in the walk-in refrigerator (pies, cookies, fruit cups) were not covered to protect from contaminants. * Several containers of food in the walk-in refrigerator were not fully sealed. Opened or leftover food items that were stored in the refrigerator were not consistently dated. * An employee's sweatshirt was tossed on a wire shelving unit used to store bakeware. * Wet rags with visible debris were left laying on counters. Staff were observed wiping down counters later without rinsing the rags in a sanitizing solution. * A staff person was observed handling clean dishware without having sanitized his hands after previously handling soiled items. * Staff 3 (Cook) failed to check the temperature of fried veal cutlets to determine if they had reached the proper internal cooking temperature. The areas needing cleaning and repair, and the failure to follow safe food handling and preparation practices was reviewed on 08/11/22 at 2:30 pm with Staff 2 (Dining Services Coordinator) and with Staff 1 (Executive Director) at 2:45 pm. They acknowledged the findings.

The community has instituted a cleaning schedule touching all topics referenced in the SOD, that all kitchen staff have been trained on by the Dining Service Coordinator. Kitchen staff will sign off on the training and mark off cleaning tasks as completed. All noted maintenance items in SOD have been repaired and in good working order and cleanliness. 2) The Dining Service Coordinator will monitor the cleaning schedule and hold ktichen staff accountable, re-train and audit as needed to ensure quality control. 3)  Evaluated and audited daily. 4) Dining Services Coordinator for all mentioned cleaning and training items. Maintenance Director for all mentioned maintenance and repair items.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the ALF main kitchen and food storage areas on 11/22/22 identified the following deficiencies:    * Splatters, spills, drips or debris were observed on:   - Floors throughout the kitchen, walk-in refrigerator and walk-in freezer;   - Wire storage racks in the walk-in refrigerator;   - The can opener blade; and   - Inside of plate warmer cabinet. * Plastic bins of oat flakes in the dry storage room were uncovered and oats had been spilled on lower shelves and the floor. * An employee was seated and eating a meal in the dry storage room; and * An employee's thermal lunch container was stored in the walk-in refrigerator. The areas needing cleaning and the failure to follow safe food handling and preparation practices was reviewed on 11/22/22 with Staff 5 (Executive Director). He acknowledged the findings.

Facility will provide written training to all dining staff with the cleaning schedule, touching on all parts noted in re-survey. Dining Services Manager will audit the memory care kitchen, food storage, and dining areas and the signed cleaning log daily. Daily Dining Services Manager

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the ALF main kitchen and food storage areas on 2/3/23 identified the following deficiencies:    * Splatters, spills, drips, dust and/or debris were observed on:   - Floors behind, underneath and beside equipment and open shelving;   - Vents and fire sprinklers;   - Grill top, back splash and behind grill;   - Stove top, exterior and interior of regular and convection ovens;   - Ceiling and wall of walk in cooler;   - Cooling fan covers in freezer;   - Walls behind juice machine and by entrance/exit door to dining room;   - Open shelving above steam table and where spices were stored;   - The can opener blade and casing;   - Interior and exterior of microwave and toaster; and   - Inside of plate warmer cabinet. * There were 2 holes observed under a prep area table. They were acknowledged by Staff 1 (Executive Director). There was significant ice build up on the door to the walk in freezer, in the walk in freezer as well and noted dripping and rusting areas in the walk in cooler. A large section of exposed pressed wood by a window seal was observed from the smooth cleanable surface pealing off. * Multiple items in walk in cooler found not labeled or dated. * Multiple items in walk in cooler found uncovered. * Multiple employees found not washing hands when entering kitchen area as well as not washing hands when changing from dirty tasks to clean tasks. * Kitchen staff observed to heat up a can of tomato soup and did not check the temperature before serving to resident. * Lunch item temperatures were not checked prior to start of service. They were removed from convection oven, placed in steam table, covers removed and staff served residents. Temperature logs were reviewed and multiple days of food temperatures were not recorded. Staff 1 (Executive director) and Staff 2 (Dining Services Coordinator) acknowledged temperatures were not recorded. * Cleaning task list and schedule was reviewed with Staff 2 and she validated multiple days were missing documentation. She did state that staff frequently forget to write it down. * Plan of correction presented by facility included weekly audits. Staff 1 was asked for documentation that audits had been conducted and none was provided. The areas needing cleaning and the failure to follow safe food handling and preparation practices was reviewed on 2/3/23 with Staff 1 (Executive Director). He acknowledged the findings.

Facility will implement  Brookdale Menu Manager menus approved by Crandall Corporations Dieticians  as well as real time trainings with kitchen staff. Will follow the Daily Diet Modification sheets. Will provide mid morning, mid afternoon, and evening snacks daily. Utilization of proper portioning serving tools to monitor correct servings of food served Menus will be planned at least 2 weeks in advance and provide residents their copies of the menus. Any substitution will be recorded on the Menu Substitution Log Dining Services Manager, Interim Director, Memory Care Administrator will monitor compliance by doing daily documented audits. Educating our Dining associates by inservices and actual real time trainings in Food safety and sanitation. ALF Main Kitchen Cleaning Schedule is in place. - Floors have been cleaned and is maintained by following cleaning schedules daily. Sweep and mop every after meal or as needed. - Maintenance have scheduled clean up and repairs of vents and fire sprinklers. - Scrubbed, clean and maintaining oven, grill and stovetop area by schedule, done daily by designated associate. - Finished cleaning cooler ceiling and walls. Scheduled cleaning is in place, or clean as needed. - Maintenance contacted repair company to fixed freezer/cooler. - Walls behind juice machine cleaned and being maintained daily. - Open shelving for spices is now organized and being maintained daily - Ordered new can opener to be installed - Microwave in brand new and daily clean up is part of assigned cleaning schedule - Scrubbed and cleaned plate warmer. Daily clean up is part of assigned cleaning schedule - 2 holes have been patched and will be painted - Replaced pressed wood with real wood and will be painted - Dining Leader continues to monitor practice of proper dating and food labeling - inserviced culinary associates. - Spot audits are being done by different department heads to ensure compliance in food safety and sanitation. - Proper heating of RTE food addressed. Instructed servers to request assistance from the cooks to properly take temperatures of any food before serving - Inservices going on for proper food holding temperatures of cold and hot foods. Taking and documenting internal temperatures of food to know if temperatures are correct before placing in steam table. Taking temperatures of food before start of meal service and every 30 mintes thereafter. Hot food should be kept hot, cold foods cold. - Temperature Logs are in place. Dining Leader monitors and inforce daily Continually training and coaching associates to be compliance in Food Safety and Sanitation.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety or welfare of residents. Findings include, but are not limited to: Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room. During observations of the ALF main kitchen on 11/22/22 between 11:55 am and 12:30 pm, multiple kitchen staff were observed not wearing masks properly, exposing their noses and mouths. The need for the facility to ensure all staff consistently follow current masking requirements was reviewed with Staff 5 (Executive Director). He acknowledged the findings.

Facility will provide written counselling to the staff observed not wearing a mask properly, and written training to all staff regarding mask expectations. Written training will be provided to all memory care staff, and enforced daily The memory care community will be walked daily, and staff on duty observed to ensure masks are being worn properly. Executive Director

Based on interview and observation, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240 and C 295.

Please refer to C240

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

Refer to C 240

The findings of the kitchen inspection, conducted 08/11/22, 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 Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen survey of 08/11/22, conducted 11/22/22, 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 11/22/22, conducted 2/3/23, 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 third revisit to the kitchen inspection of 08/11/22, conducted 04/27/23, 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.