Brookdale Geary Street

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.

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.

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.

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

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

This Rule is not met as evidenced by:

Based on observation 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.

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

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

This Rule is not met as evidenced by:

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a dayA 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 InstructionThe 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day




The findings of the 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, 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.

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.

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.

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.

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 to1. 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 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.
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.
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.

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.

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.
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.

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.

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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered NurseNotes 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.

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 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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

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

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview, 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.