Lakeview Senior Living

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: 1. On 11/21/25 at 10:00 am, the facility main kitchen was observed to need cleaning in the following areas: a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following: * Sides of ovens and steamer; * Wall and pipes behind ovens; * Metal shelf beneath steamer; *Walls, pipes, garbage disposal and floor drain in dish machine area, * Wall next to fire extinguisher; * Floor drain near two-compartment sink; and * Flooring throughout including perimeter, underneath appliances and shelving units, and in dry storage area. b. The following areas needed repair: * Caulking in the dish machine area was discolored; and * Dry storage room: scraped areas and rust stains on the door jamb, gouges on the door edges, and scrapes/gouges to the wall adjacent to the entrance. c. Three dietary staff, with facial hair, did not have it restrained. The areas in the main kitchen which required cleaning and repair were observed and discussed with Staff 1 (ED) and Staff 2 (Culinary Services Director) on 11/21/25 at 11:00 am. Additionally, the need to ensure dietary staff had facial hair restrained was discussed. The findings were acknowledged.

1. In service training with all dining staff to educate on facial hair coverings, cleaning procedures and best practices for using cleaning logs. This training will be conducted by the Culinary Director on Dec. 4th, 2025. Additional in service trainings will be conducted an a weekly and as needed basis until all deficencies are corrected and systems for maintaining compliance are learned by all dining staff. Thourough deep cleaning of all floors, walls, cooking equipment, metal shelves, pipes, florr drains, sinks and especially concentrating on the perimeter as noted on the report. This cleaning will be done by kitchen staff, maintence staff and will be overseen by the culinary director. Weekly and daily projects will begin immediately and the kitchen will be ready for reinspection by January 15th, 2026 Repairs of walls, paint, rusted hinges and caulking in dishroom will be done by the maintenance director starting on Dec 8th, 2025, with projects scheduled to be complete and in compliance by Jan 15th, 2026. A proper cover for the stand mixer will be ordered and implemented immediately. The stand mixer will be covered when not in use. Compliance will be complete on or before Jan. 15th, 2026 2. Cleaning logs will be updated to reflect current eqipment and highlighting the perimeter cleaning needs to be addressed on daily and weekly schedules. These logs will be filled out by all dining staff on every shift starting immediately and compliance will be reached on or before Jan. 15th, 2026 Cleaning tasks will be assigned to positions and shifts rather than left for a volunteer basis to ensure accountability. Audits of cleaning logs will be done daily by the culinary director. Weekly TELS audits will be completed by the Culinary Director and submitted to the Regional Culinary Director and the Senior Executive Director. TELS is an online tool that uses photos and typed comments to show compliance in areas of cleaning, menu creation, use of logs/auditing etc. Corrective action including education, verbal and written counseling, suspension and termination will be used to hold dining services staff accountable to using these systmes and maintaining compliance. The Culinary Director and Senior Executive Director will work as a team to correct dining staff that struggle to maintain best practices and compliance standards. 3. The main kitchen and Memory Care kitchenette will be evaluated/ audited weekly by the Culinary Director using paper logs and the TELS audit tool. The main ktchen and Memory Care kitchen will be evaluated monthly by the Senior Executive Director and the Program Director to ensure accountability of the Culinary Director. 4. All corrections and completion deadlines will be monitored by the Culinary Director with support by the Maintenance Director, the Program Director and the Senior Executive Director All compliance corrections will be completed on or before January 15 th, 2026.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation, interview, and record review, conducted during a site visit on 02/11/25, the facility's failure to update an acuity-based staffing tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated all 51 residents were included in the tool and had a completed ABST evaluation. There had been 11 residents that had not been quarterly reviewed. A review of the facility's ABST indicated the "minimum time needed based on acuity" on day shift was 2.34 direct care staff and less than one direct care staff for night shift. A review of the facility's posted staffing plan indicated the following:  Day shift: Two caregivers and two med techs; and  Night shift: Two caregivers and one med tech. A review of the facility's staff schedule and timecards dated 02/04/25 to 02/11/25, indicated the facility had been short staffed on 02/09/25 on day shift and 02/11/25 for day and night shift. An interview with Staff 1 (Executive Director) and Staff 3 (Registered Nurse) indicated the following;  Staff 3 was in the process on updating resident's service plans that had not been quarterly evaluated.  Staff 1 acknowledged the residents whose acuity had not been quarterly updated in the ABST. It was determined the facility failed to fully implement and update an acuitybased staffing tool. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

Based on observation, interview, and record review, conducted during a site visit on 02/11/25, the facility's failure to update an acuity-based staffing tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated all 51 residents were included in the tool and had a completed ABST evaluation. There had been 11 residents that had not been quarterly reviewed. A review of the facility's ABST indicated the "minimum time needed based on acuity" on day shift was 2.34 direct care staff and less than one direct care staff for night shift. A review of the facility's posted staffing plan indicated the following:  Day shift: Two caregivers and two med techs; and  Night shift: Two caregivers and one med tech. A review of the facility's staff schedule and timecards dated 02/04/25 to 02/11/25, indicated the facility had been short staffed on 02/09/25 on day shift and 02/11/25 for day and night shift. An interview with Staff 1 (Executive Director) and Staff 3 (Registered Nurse) indicated the following;  Staff 3 was in the process on updating resident's service plans that had not been quarterly evaluated.  Staff 1 acknowledged the residents whose acuity had not been quarterly updated in the ABST. It was determined the facility failed to fully implement and update an acuitybased staffing tool. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

Based on interview and record review, conducted during a site visit on 07/08/24 and 07/09/24, it was confirmed the facility failed to ensure the completeness and accuracy of resident records for 1 of 1 sampled resident (#3). Findings include, but are not limited to: Resident 3 no longer resided in the facility. Compliance Specialist was unable to interview resident. During an interview on 07/09/24, Staff 1 (Executive Director) indicated no knowledge of Residents POLST. Staff 1 could not explain why the information on Resident 3's POLST and service plan did not match and had not been accurate to Resident 3's preference. A review of Resident 3's service plans dated 02/25/24 and 07/04/24 indicated resident was a do not resuscitate (DNR). Both service plans had not been signed off by the resident or resident's representative. A review of Resident 3's POLST dated 03/23/21 indicated resident was not a DNR and would like to be resuscitated and given CPR. The resident's service plan and POLST status had not matched. It was confirmed the facility failed to ensure the completeness and accuracy of resident records. On 07/09/24, the findings were reviewed with and acknowledged by Staff 1.

Based on interview and record review, during a site visit conducted on 07/08/24 and 07/09/24, it was confirmed the facility had not completed quarterly service plan evaluations. Findings include, but are not limited to: During an interview on 07/09/24, Staff 1 (Executive Director) indicated there had been ten service plans that had not been updated quarterly. An email correspondence on 07/17/24, between Staff 1 and Compliance Specialist indicated the following service plans to be out of date; ·Resident 5: Service plan dated 04/10/24. Due date of quarterly service plan evaluation: 07/10/24. ·Resident 6: Service plan dated 04/10/24. Due date of quarterly service plan evaluation: 07/10/24. ·Resident 7: Service plan dated 06/05/24. Due date of quarterly service plan evaluation: 07/05/24. ·Resident 8: Service plan dated 06/05/24. Due date of quarterly service plan evaluation: 07/05/24. ·Resident 9: Service plan dated 03/31/24. Due date of quarterly service plan evaluation: 07/01/24. ·Resident 10: Service plan dated 03/31/24. Due date of quarterly service plan evaluation: 07/01/24. ·Resident 11: Service plan dated 03/13/24. Due date of quarterly service plan evaluation: 06/13/24. ·Resident 12: Service plan dated 03/11/24. Due date of quarterly service plan evaluation: 06/11/24. ·Resident 13: Service plan dated 02/25/24. Due date of quarterly service plan evaluation: 05/25/24. ·Resident 14: Service plan dated 02/23/24. Due date of quarterly service plan evaluation: 05/23/24. It was confirmed the facility had not completed quarterly service plan evaluations. On 07/09/24, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The facility has been working on updating resident service plans to be up to date and person centered. Staff 1 indicated all service plans would be complete and updated in two weeks.

Based on observation, interview, and record review, conducted during a site visit on 07/08/24 and 07/09/24, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to: CS observed the following, · Staff for Day shift (6:00 AM through 6:00 PM) on 07/08/24 and 07/09/24: two CG and two MT. · Staff for Night shift (6:00 PM through 6:00 AM) 07/08/24: two CG and one MT. During an interview on 07/09/24, Staff 1 (Executive Director) indicated the facility ABST was not in compliance. S/he indicated there had been ten service plans that had not been quarterly updated. An email correspondence on 07/17/24, between Staff 1 and Compliance Specialist indicated the following service plans to be out of date; · Resident 5: Service plan dated 04/10/24. Due date of quarterly service plan evaluation: 07/10/24. · Resident 6: Service plan dated 04/10/24. Due date of quarterly service plan evaluation: 07/10/24. · Resident 7: Service plan dated 06/05/24. Due date of quarterly service plan evaluation: 07/05/24. · Resident 8: Service plan dated 06/05/24. Due date of quarterly service plan evaluation: 07/05/24. · Resident 9: Service plan dated 03/31/24. Due date of quarterly service plan evaluation: 07/01/24. · Resident 10: Service plan dated 03/31/24. Due date of quarterly service plan evaluation: 07/01/24. · Resident 11: Service plan dated 03/13/24. Due date of quarterly service plan evaluation: 06/13/24. · Resident 12: Service plan dated 03/11/24. Due date of quarterly service plan evaluation: 06/11/24. · Resident 13: Service plan dated 02/25/24. Due date of quarterly service plan evaluation: 05/25/24. · Resident 14: Service plan dated 02/23/24. Due date of quarterly service plan evaluation: 05/23/24. A review of the posted staffing plan and the facility ABST indicated the following; · Day shift from 6:00 AM to 2:00 PM staffed with two med techs and two caregivers. · Swing shift from 2:00 PM to 10:00 PM staffed with two med techs and two caregivers. · Night shift from 10:00 PM to 6:00 AM staffed with one med techs and two caregivers. It was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). On 07/09/24, the findings were reviewed with and acknowledged by Staff 1.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to implement a service plan that reflects the resident's needs for 3 of 3 sampled residents (#s1, 2, and 3). Findings include, but are not limited to: During an interview on 06/12/24, Staff 1 (ED) indicated the facility was cited during their survey conducted on 05/21/24 for service plans not being person centered. Staff 1 indicated s/he and Staff 2 (RCC) had been working on changing and updating all resident service plans. A review of service plans indicated the following; ·  Resident 1 service plan dated 05/17/24, indicated resident was independent with showers. Staff are to provide stand by assistance with showers to help reduce falls. ·  Resident 2 service plan dated 04/22/24, indicated resident was a one person full assist twice per week. ·  Resident 3 service plan dated 04/30/24, indicated resident was a two person full assist twice per week. A review of the shower schedule indicated the following; ·  Resident 1 scheduled for showers on swing shift for Monday and Wednesdays. ·  Resident 2 scheduled for showers on swing shift for Sunday and Thursdays. ·  Resident 3 scheduled for showers on day shift for Wednesday and Saturdays. A review of shower sheets from 04/01/24 through 06/05/24 provided from the facility indicated the following; ·  Resident 1 had not been provided eighteen of twenty showers during the timeframe. ·  Resident 2 had not been provided fifteen of eighteen showers during the timeframe. A shower sheet on 04/20/24, noted residents '  hair was matted and scalp was irritated and scabby. ·  Resident 3 had not been provided five of nineteen showers during the timeframe. It was confirmed the facility failed to implement a service plan that reflects the resident's needs. On 06/12/24, the findings were reviewed with and acknowledged by Staff 1. Verbal POC: ED and RCC have been going through all resident's service plans to make them more person centered. ED will bring back shower sheet and ensure staff have completed them and will audit to ensure showers are being provided.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to ensure the staff person who administers the medication must visually observe the resident take the medication for 1 of 3 sampled residents (#1). Findings include, but are not limited to: During an interview on 06/12/24, Staff 1 (ED) indicated there had been issues with staff not observing residents take his/her medications. Staff 1 stated s/he had planned to request an order from Resident 1's physician to allow medications to be left at bedside, as this was Resident 1's preference. S/he acknowledged there was no current order. During an interview on 06/12/24, Resident 1 stated, "There have been times staff has left my medication on the counter since it takes me awhile to take my medication in the morning." A review of the service plan for Resident 1 dated 05/17/24, indicated the resident required assistance with medication two times a day. It was confirmed the facility failed to ensure the staff person who administers the medication must visually observe the resident take the medication. On 06/12/24, the findings were reviewed with and acknowledged by Staff 1. Verbal POC: The facility will follow the doctor's orders as prescribed effective immediately. The ED will reach out to doctor for approval to get a bedside medication order.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: During an interview on 06/12/24, Resident 1 indicated call light response times take longer than 20 minutes to get staff to respond and assist. Resident 1 indicated s/he had not received showers due to lack of staff. During an interview on 06/12/24, Staff 1 (Executive Director) indicated the facility scheduled two 12-hour shifts and does not follow the three 8-hour shifts. A review of the posted staffing plan indicated the following: · Day shift: Two caregivers and two med techs. · Swing shift: Two caregivers and two med techs. · Night shift: Two caregivers and one med tech. A review of the facility's staff schedule and timecards for 04/01/24 through 04/03/24 and 04/25/24 through 05/01/24, indicated the facility was consistently staffing to their posted staffing plan. A review of the facility-wide call light history report dated 04/25/24 through 05/01/24 indicated 32 call light response times that had exceeded 15 minutes. Twenty of those response times had exceeded 20 minutes with the longest wait time of 30 minutes. A review of service plans indicated the following: · Resident 1's service plan dated 05/17/24, indicated resident was independent with showers. Staff are to provide stand by assistance with showers to help reduces falls. · Resident 2's service plan dated 04/22/24, indicated resident was a one-person full assist twice per week. · Resident 3's service plan dated 04/30/24, indicated resident was a two-person full assist twice per week. A review of the shower schedule indicated the following: · Resident 1 scheduled for showers on swing shift for Monday and Wednesdays. · Resident 2 scheduled for showers on swing shift for Sunday and Thursdays. · Resident 3 scheduled for showers on day shift for Wednesday and Saturdays. A review of shower sheets, dated 04/01/24 through 06/05/24, provided from the facility indicated the following: · Resident 1 had not been provided eighteen of twenty showers during the timeframe. · Resident 2 had not been provided fifteen of eighteen showers during the timeframe. A shower sheet on 04/20/24, noted residents' hair was matted and scalp was irritated and scabby. · Resident 3 had not been provided five of nineteen showers during the timeframe. It was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. On 06/12/24, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: Staff 1 will continue to audit call lights and will ensure showers are completed.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to: During an interview on 06/12/24, Staff 1 (Executive Director) indicated the facility had been scheduling for two 12-hour shifts and was not appropriately staff to accommodate three 8-hour shifts. The facility had one resident who required two-person transfer and the current census was 49 residents. A review of the posted staffing plan and the facility ABST indicated the following; · Day shift from 6:00 AM to 2:00 PM staffed with two med techs and two caregivers. · Swing shift from 2:00 PM to 10:00 PM staffed with two med techs and two caregivers. · Night shift from 10:00 PM to 6:00 AM staffed with one med tech and two caregivers. A review of the facility's staff schedule and timecards, dated 04/01/24 through 04/03/24, and 04/25/24 through 05/01/24, indicated the facility was consistently staffing to their posted staffing plan. A review of service plans indicated the following; · Resident 1 service plan dated 05/17/24, indicated resident was independent with showers. Staff are to provide stand by assistance with showers to help reduces falls. · Resident 2 service plan dated 04/22/24, indicated resident was a one-person full assist twice per week. · Resident 3 service plan dated 04/30/24, indicated resident was a two-person full assist twice per week. A review of the shower schedule indicated the following; · Resident 1 scheduled for showers on swing shift for Monday and Wednesdays. · Resident 2 scheduled for showers on swing shift for Sunday and Thursdays. · Resident 3 scheduled for showers on day shift for Wednesday and Saturdays. A review of shower sheets from 04/01/24 through 06/05/24 provided from the facility indicated the following; · Resident 1 had not been provided eighteen of twenty showers during the timeframe.   · Resident 2 had not been provided fifteen of eighteen showers during the timeframe. A shower sheet on 04/20/24, noted residents'  hair was matted and scalp was irritated and scabby. · Resident 3 had not been provided five of nineteen showers during the timeframe. It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. On 06/12/24, the findings were reviewed with and acknowledged by Staff 1.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to have a training program that includes abuse and reporting requirements. Findings include, but are not limited to: During separate interviews on 06/12/24, Staff 1 (ED) indicated the facility was cited during their survey conducted on 05/21/24 for incomplete training records including abuse and reporting. The facility will have an all-staff training on Friday 06/14/24 to go over abuse and reporting practices. When Staff 6 (MT) was asked the procedure for abuse and reporting, Staff 6's response was to contact the RCC, and s/he was not familiar with the correct policy and procedure for reporting. A review of the facility policy and procedure for elder abuse, neglect, and exploitation dated 12/09/21 indicated all personal care attendants will receive in-service training on elder abuse incidents, signs and symptoms of abuse, and reporting requirements during initial orientation. A review of Staff 3 (MT), Staff 4 (MT), and Staff 5's (CG) 30-day competency training records indicated Staff 3 and Staff 4 had complete training which included when to fill out incident report and call 911. The facility could not provide Staff 5's competency checklist. The three staff had completed the Relias training which included preventing, recognizing, and reporting abuse. It was confirmed the facility failed to have a training program that includes abuse and reporting requirements. On 06/12/24, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The company and facility are working together to create a more extensive training program to include knowledge of abuse and reporting. ED will ensure all staff have completed required training within 30 days.

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, which posed a risk to the safety of residents. Findings include, but are not limited to: During the re-licensure survey, conducted 05/20/24 through 05/23/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations. Refer to deficiencies in report.

1. Executive director to provide oversight. Including training , supervision and overall conduct for all staff. 2.  Daily review and ED rounds for oversight. 3. Daily. 4. Executive Director.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: During the survey, multiple non-sampled residents expressed their concerns during a group interview as well as individual interviews regarding complaints being minimized or going unaddressed. Examples given included: * Food was served cold; * No resident suggestion box; * Lack of staff; * Call light response time was too long; * Property theft; and * "They said they would look into it and I never heard back." On 05/22/24, Staff 1 (Executive Director) was interviewed about the facility's grievance resolution policy. She stated the facility had a grievance resolution policy, however, she had not yet implemented the system which included documenting the response to and resolution of resident complaints. The need to ensure the facility had an effective method of responding to and resolving resident complaints was discussed with Staff 1 on 05/22/24. She acknowledged the findings.

1. Implementation of resident grievances and complaints through investigation and resolutions. 2. Town Hall meetings will occur monthly with residents addressing grievances and concerns. Follow up meeting minutes including resolutions will be provided to all residents. 3. As grievances and concerns arise as well as monthly. 4. ED, RSD, RN, PD, BOD, CRD, CD, MD and LD

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings included, but are not limited to: During the re-licensure survey, conducted 05/20/24 through 05/23/24, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective. The need to ensure the facility developed and conducted an ongoing quality improvement program that evaluated services, resident outcomes, and satisfaction was discussed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged. Refer to the deficiencies in the report.

1.Development of a quality improvement program to evaluate services, resident outcomes and resident satisfaction. 2. Implantation of Town Hall meetings. Addressing resident concerns Residents will receive copies of Town Hall meeting minutes and resolutions. Placement of suggestion boxes were placed in a public setting which is accessible to all residents. 3. Monthly 4. ED, PD, RSD, MD, CD, RN, BOD, LD, CRD

Based on observation and interview, it was determined the facility failed to ensure residents were treated with dignity and respect when receiving meal delivery to their apartments. Findings include, but are not limited to: During meal service observations from 05/20/24 through 05/23/24, meals delivered to resident rooms were served on paper plates, drinks were served in disposable cups, and utensils were plastic. The meals served to residents in the dining room were served on ceramic dishes with stainless steel flatware. During an interview on 05/23/24, Staff 6 (Culinary Director) stated all meals delivered to residents in their rooms were served on disposable products. Staff 6 reported that the warmer used for transport held only ten trays and that currently, up to approximately 25 residents were choosing to eat in their rooms. Staff 6 stated meal service to rooms had been attempted with non-disposable products at one point but that logistics had caused the facility to return to disposable products. Ensuring residents were treated with respect and dignity regarding meal service was discussed on 05/23/24 with Staff 2 (Resident Services Director) and was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone. The findings were acknowledged.

1.All meals are now being served on glass plates with aluminum foil wrap to secure temps and for presentation. With the exception of residents who prefer paper to go boxes. Preferences will be  captured in service plans. 2. Facility has eliminated all styrofoam containers for meal services. 3. Correction was effective immediately. 4. Culinary Director and food service staff

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#5) whose new move-in evaluation was reviewed. Findings include, but are not limited to: Resident 5 moved into the facility in 02/2024. A review of Resident 5's move-in evaluation, dated 02/23/24 and 02/26/24, identified the facility failed to address the following required elements: * Interests, hobbies, social, and leisure activities; * Spiritual, cultural preferences and traditions; * Personality: including how the resident coped with change or challenging situations; * Pain: non-pharmaceutical interventions, including how s/he expressed pain or discomfort; and * History of dehydration or unexplained weight loss or gain. During an interview with Staff 2 (Resident Services Director) on 05/23/24 at 11:30 am, she reviewed the record and acknowledged the findings. The need to ensure move-in evaluations included all required elements was discussed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged. No further documentation was provided.

1. Activity profile will be conducted for Resident #5 including hobbies, spirituality, personality, pain, history of dehydration/weight loss and gain. Move-in evaluations will reflect all ADL's plus residents preferences and accommodations. 2. Detailed evaluations will be completed by RSD, RSC and RN, LD. 3. Upon admission, 30 days, 90 days and chance of conditions. 4. ED, RSD, RSC, LDand RN

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and provided clear direction to staff for 2 of 4 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression, hypothyroidism, and chronic obstructive pulmonary disease. The resident's clinical record was reviewed, including service plan dated 05/17/24 and progress notes and temporary service plans dated 03/02/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted. The resident's service plan was not reflective and/or lacked resident-specific direction for staff in the following areas: * Activities; * Oxygen; * Refusal of care; * Meals/nutrition; and * Behaviors. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided. 2. Resident 4 was admitted to the facility in 01/2023 with diagnoses including anxiety, chronic pain and depression. The resident's clinical record was reviewed, including service plan dated 05/12/24 and progress notes and temporary service plans dated 01/01/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted. The resident's service plan was not reflective and/or lacked resident-specific direction for staff in the following areas: * Reminders for meal time; * Behaviors; * Recommendations from outside providers; * Location of pain and non-pharmacological interventions; * Activities; and * Care of cat. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

1.  Detailed person centered information will be gathered for resident #1 and #4 capturing resident specific and clear direction for staff  to provide proper care needs and implemented into the service plan. 2. Service plan team will meet with individuals prior to admission providing an evaluation to gather preferences to implement into the service plan. 3.Admission, 30 days, quarterly and change of condition as needed. 4. Service planning team.

3. Resident 3 was admitted to the facility in 05/2016 with diagnoses including hypertension and a history of UTI's (urinary tract infections). Observations and interview with the resident, and interviews with staff were completed. The resident's service plan dated 04/10/24, progress notes dated 01/20/24 through 05/20/24, and incident investigations were reviewed. The following was revealed: a. The following short-term change of condition lacked documentation of resident-specific actions or interventions needed, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly, and/or documentation of resolution: * 05/02/24: Increased confusion and possible UTI. b. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed and communication of the determined actions or interventions to staff on all shifts: * 02/15/24: UTI; * 02/22/24: Buttock wound; and * 05/12/24: Fall. The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and the changes of condition were monitored weekly through resolution was discussed with Staff 2 (Resident Services Director) on 05/21/24 at 10:35 am, and during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged. 4. Resident 2 was admitted 07/2020 with diagnoses which included a history of skin breakdown and diabetes. Observations and an interview with the resident, interviews with staff, review of the service plan dated 05/17/24, incident investigations, home health documentation, a hospital discharge summary, and progress notes dated 01/24/24 through 05/20/24 were reviewed. The following was revealed: a. A progress note, dated 04/08/24, indicated the resident was "throwing up" and was sent to the hospital. A hospital discharge summary revealed the resident had been admitted to the hospital on 04/08/24 for "Sepsis due to Streptococcus ..." S/he was discharged on 04/12/24 (four days later) and returned to the facility. There was no evidence the facility evaluated the resident's change in condition, referred the change to the facility RN, or monitored the resident consistent with his/her evaluated needs. In an interview on 05/23/24, Staff 2 (Resident Services Director) reviewed the resident's record and acknowledged the findings. No further information was provided. b. The following short-term change of condition lacked documentation of progress noted at least weekly, and/or documentation of resolution: * 02/15/24: Insulin not administered; * 02/27/24: Insulin not administered; * 03/15/24: Medication discontinued; and * 04/14/24: Low blood sugar. On 05/23/24 at 8:40 am, Staff 2 (Resident Services Director) reviewed the record and acknowledged the findings. The need to ensure Resident 2's short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, and significant changes in condition were evaluated, referred to the facility RN, and monitored consistent with the resident's evaluated needs was discussed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged. No further documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, changes were reported to the RN when needed, and progress was documented weekly until resolution for 4 of 4 sampled residents (#s 1, 2, 3 and 4). Resident 1 experienced a severe weight loss and continued to lose weight. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression, hypothyroidism, and chronic obstructive pulmonary disease. The resident's clinical record was reviewed, including weight records dated 01/25/24 through 05/07/24, service plan dated 05/17/24, 05/2024 MAR, and progress notes, temporary service plans and incident reports dated 02/20/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted. a. The resident's weight records stated: * 01/27/24 - 165 pounds; and * 02/23/24 - 161.2 pounds. On 03/15/24 Resident 1 was admitted to the hospital due complaint of right arm numbness and tingling and inability to move his/her right hand. S/he returned to the facility 19 days later on 04/03/24 with diagnoses including ischemia of right upper extremity and having undergone a right arm fasciotomy surgery. During interviews on 05/21/24 and 05/22/24, multiple staff stated that upon returning from the hospital the resident appeared to have lost weight and had a significant increase in care needs including wound monitoring and ADL care. There was no documentation that the facility evaluated the resident, referred to the facility nurse, or updated the service plan upon his/her return from the hospital. Prior to the resident's hospital admission, his/her weight was recorded as: * 01/27/24 - 165 pounds; and * 02/23/24 - 161.2 pounds. The resident was weighed on 04/14/24,  11 days after returning from the hospital, and weighed 139.1 pounds. This constituted a severe weight loss of 15.7%, or 25.9 pounds in three months. There was no documented evidence that the facility evaluated the severe weight loss recorded on 04/14/24, referred to the facility nurse, or updated the service plan as needed. The resident continued to experience weight loss. On 05/07/24, the resident's weight was recorded as 128.2 pounds. This constituted a severe weight loss of 7.8%, or 10.9 pounds, in one month. During an interview on 05/20/24, Staff 2 (Resident Services Director) stated the facility was aware of the resident's weight loss, and that Staff 3 (RN) had completed a significant change of condition assessment on 05/17/24, though she did not currently have access to it as it was on Staff 3's computer which was outside the facility. No new interventions had been put into place or communicated to staff. On 05/22/24, Staff 3 (RN) acknowledged the multiple severe weight losses and stated she was not able to identify when she was notified of the weight loss. The facility failed to evaluate Resident 1's severe weight loss, refer to the nurse, and update the service plan as needed, and the resident continued to experience severe weight loss. Refer to C 280, example 1. b. Resident 1 experienced the following changes of condition without interventions or actions determined, documented and communicated to staff on all shifts, and/or monitored weekly through resolution: * 02/29/24 - Medication change; * 03/02/24 - Fall with pain and bruising to left knee;; * 03/07/24 - Medication change; * 03/07/24 - Fall with pain and bruising to wrist and back; * 03/10/24 - Fall with lower back pain and return from ER; * 03/11/24 - Fall, no injury; * 03/11/24 - Fall with pain to right elbow and ribs; * 03/12/24 - Altered mental status and return from ER with medication changes; * 03/13/24 - Fall; * 04/03/24 - Return from hospital stay 03/15/24 through 04/03/24 with surgery to right elbow, change in medications and ADL participation; and * 04/19/24 - Fall with report of hitting head. The need to ensure changes of condition were evaluated, actions or interventions determined, documented and communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (ED) and Staff 2 on 05/22/24. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 01/2023 with diagnoses including anxiety, chronic pain and depression. The resident's clinical record was reviewed, including the service plan dated 05/12/24, 05/2024 MAR, and progress notes, temporary service plans and incident reports dated 01/01/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted. Resident 4 experienced the following changes of condition without interventions or actions determined, documented and communicated to staff on all shifts, and/or monitored weekly through resolution: * 01/24/24 - Unwitnessed fall at 3:00 am; * 01/24/24 - Unwitnessed fall at 8:00 am; * 01/24/24 - Unwitnessed fall at 1:20 pm; * 04/24/24 - Behaviors including asking a staff member for pain medication to sell; * 04/17/24 - Behaviors including verbal aggression towards staff and other residents; and * 04/22/24 - Behaviors including yelling at staff and walking into another resident's room. The need to ensure changes of condition had actions or interventions determined, documented, and communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

1.RN oversight and assessment on all changes of conditions. Residents 1, 2, 3 and 4 the last two weeks were reviewed to rule out any short term change of conditions. Any change of condition identified will further be evaluated and reviewed with staff 2. RN will conduct all significant and short term changes of conditions. Providing oversight, documentation and follow through. 3.  RSD or designee will audit the 24 hour book 5 days a week to ensure all short term COC's and TSP's  are placed on alert. Clinical services team will review documentation weekly to ensure information is documented. Documentation will be reviewed monthly and clinical review meetings until deficient practice is complete. RSC or designee will alert RN of any short term COC's that is not resolving to trigger a comprehensive COC. Any short term COC will be in a 24hr book. RSC/PD will check daily to ensure proper resolution. 4. RN

2. Resident 2 was admitted 07/2020 with diagnoses which included a history of skin breakdown and diabetes. Observations and an interview with the resident, interviews with staff, review of the service plan dated 05/17/24, incident investigations, home health documentation, a hospital discharge summary, and progress notes dated 01/24/24 through 05/20/24 were reviewed. The following was revealed: A progress note, dated 04/08/24, indicated the resident was "throwing up" and was sent to the hospital. A hospital discharge summary revealed the resident had been admitted to the hospital on 04/08/24 for "Sepsis due to Streptococcus ..." S/he was discharged on 04/12/24 (four days later) and returned to the facility. The decline in health and hospitalization constituted a significant change in condition for which an assessment by the facility RN was required. There was no documented evidence the facility RN conducted an assessment. During an interview on 05/23/24 at 8:40 am, Staff 2 (Resident Services Director) reviewed the record and acknowledged an RN assessment had not been completed. Staff 3 (RN) was not available for interview. The need to ensure RN assessments were completed with significant changes in condition was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 (Resident Services Director), and Staff 4 (Business Office Director). The findings were acknowledged. No further documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by an RN, including documented findings, resident status and interventions made as a result of the assessment, for 2 of 2 sampled residents (#1 and 2) who experienced significant changes of condition. Resident 1 experienced severe weight loss and continued to lose weight. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression, hypothyroidism, and chronic obstructive pulmonary disease. The resident's clinical record was reviewed, including weight records dated 01/25/24 through 05/07/24, service plan dated 05/17/24 and progress notes dated 02/20/24 through 05/19/24, the resident was observed, and interviews with staff and the resident were conducted. a. Review of weight records revealed the following: * 01/27/24 - 165 pounds; * 02/23/24 - 161.2 pounds; and * 04/14/24 - 139.1 pounds. This constituted a severe weight loss of 25.9 pounds, or 15.7%, in three months. There was no documented evidence a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN. The resident continued to experience severe weight loss, as documented by: * 05/07/24 - 128.1 pounds. This constituted a severe weight loss of 10.9 pounds, or 7.8%, in one month. As of survey entrance on 05/20/24, the facility had no documented evidence that a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN. At the time of the survey, 05/23/24, the resident weighed 126.0 pounds. During interviews on 05/21/24 and 05/22/24, staff stated they did not have any observations of how much the resident had been eating recently as the resident ate all meals in his/her room and trashed any remaining food in the Styrofoam containers the food was delivered in. Resident 1 experienced severe weight loss between February and April of 2024, there was no documented evidence of an RN assessment to include findings, resident status, and interventions made as a result of the assessment and the resident continued to lose weight. b. Resident 1 was admitted to the hospital 03/15/24 due to change in cognition and right upper extremity numbness, and returned to the facility on 04/03/24. During the hospital stay, the resident underwent fasciotomy surgery to his/her right arm. Upon return, the resident had a surgical wound, changes in multiple medications, new activity restrictions, and an increased need for care assistance. As of 05/21/24, the facility had no documented evidence a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN. During an interview on 05/22/24, Staff 3 (RN) stated she had completed a change of condition assessment on 04/14/24 but had not provided it to the facility until emailing it to Staff 2 (Resident Services Director) on 05/22/24. The need to ensure a significant change of condition assessment was completed and documented by the RN, including findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (ED), Staff 2 and Staff 3 on 05/22/24. They acknowledged the findings.

1.RN will complete a change of condition assessment for resident number #1. Reflecting on significant weight loss. RSD will modify and capture changes in the Service plan. RN will complete a change of condition evaluation for resident #2 documenting and capturing skin condition. 2.  RN will complete all assessment for all change of conditions including decline in #1 and #2 weight loss and skin break down. 3. As needs arise RN will complete assessments for changes of conditions. 4. RN

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure service providers leave written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care if necessary for 1 of 2 sampled residents (#4) who received outside services. Findings include, but are not limited to: Resident 4 was admitted to the facility in 01/2023 with diagnoses including anxiety, chronic pain and depression. Resident 4's progress notes, dated 01/01/24 through 05/19/24, were reviewed, as well as all outside provider communications. The following was identified: a. The facility did not receive or document outside provider notes and recommendations from the resident's primary care provider visits on the following dates: * 01/18/24; * 01/30/24; * 02/27/24; * 03/12/24; * 03/26/24; * 04/09/24; and * 05/07/24. b. The resident had biweekly appointments with behavioral support services. The facility did not receive or document outside provider notes and recommendations from January 2024 through April 2024. The need to coordinate care with outside providers and ensure service providers left written information in the facility that addressed on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

1.RN and RSD to coordinate care with outside providers as well as ensure written information/instructions on services being provided or requested. Obtain bi-weekly primary care provider notes for resident #4 and monthly documentation for behavioral support services. 2. Daily Monday-Friday clinical reviews. 3. Daily Monday-Friday. 4. RN, RSD, RSC and ED

Based on observation, interview, and record review, it was determined the facility failed to ensure the staff who administered medications visually observed the resident take the medications for 1 of 1 sampled resident (#1) whose records were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression, hypothyroidism, and chronic obstructive pulmonary disease. The resident's 04/01/24 through 05/19/24 MARs and physician's orders were reviewed. During the acuity interview on 05/20/24, Staff 2 (Resident Services Director) and Staff 3 (RN) stated the facility administered all of Resident 1's medications. During an interview with Resident 1 on 05/21/24, a pill cup with six pills was observed on the resident's bedside table. The resident stated staff "often" left medications without observing him/her take them. Staff 10 (MT) stated on 05/21/24 that Resident 1 at times had difficulty taking all of his/her medications in the morning. She stated Resident 1 had requested additional time to take medications in the past. Staff 10 stated she did not leave medications in the resident's room, but had observed pill cups in the room in the past. On 05/23/24, Staff 2 stated she was aware this had occurred in the past. She stated she also had requested an order from Resident 1's physician to allow medications to be left at bedside, as this was Resident 1's preference. She acknowledged there was no current order. The need to ensure the staff person who administered medication visually observed the resident take the medication was discussed with Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

1.Staff will be retrained and educated on the importance of ensuring all medication is consumed prior to leaving the presence of resident #1. Per resident #1's request fax to PCP for a leave at bedside order has been requested. 2.  Retaining all med techs on proper policy and procedure. Residents with the preference of leaving medications at bedside primary care providers will be contacted to obtain an order clarifying the ability for staff to do so. 3. Per resident request will be reviewed Monday-Friday at daily clinical. 4. RN, RSD and RSC and ED

Based on interview and record review, it was determined the facility failed to ensure resident MARs included resident specific parameters and instructions for medications, for 1 of 3 sampled residents (#2) whose MARs were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 07/2020 with diagnoses which included high blood pressure. Resident 2 had an order for clonidine 0.1 mg one tablet three times a day for hypertension (high blood pressure). Staff were instructed to "hold for hypotension [low blood pressure]." Review of the MARs from 05/01/24 through 05/20/24 revealed the following: * Lack of clear parameters for hypotension and when the medication should be held; and * Staff were administering the medication without obtaining a blood pressure to determine if the medication should be held. In an interview on 05/22/24 at 1:20 pm, Staff 10 (MT) reviewed the resident's MAR. She confirmed the clonidine lacked specific instructions for staff including when the medication should be held. The need to ensure MARs were accurate and included clear parameters for staff was discussed with Staff 2 (Resident Services Director) on 05/22/24 at 3:45 pm, and during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone, Staff 2 and Staff 4 (Business Office Director). The findings were acknowledged. No further documentation was provided.

1. Medication procedures will be altered to allow staff to remove from the medication cart and computer from the medication room allowing staff to administer medication resident to resident removing the option to pre-pour/pop medications. RSD revised medication capturing specific parameters and instruction for resident #2's MAR. 2. Medications will no longer be pre popped prior to administration. All medications will have clear parameters and clear instruction for staff administration. 3. Per each received medication order. 4. ED, RSD, RSC, and RN

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to ensure their ability to safely self-administer medications for 1 of 1 sampled resident (#4). Findings include, but are not limited to: Resident 4 was admitted to the facility in 01/2023. During the acuity interview on 05/20/24, Resident 4 was identified as self-administering his/her own medications. On 05/22/24, Staff 2 (Resident Services Director) and Staff 3 (RN) acknowledged during separate interviews that Resident 4 did not have a quarterly evaluation completed to ensure s/he could safely self-administer his/her own medications. The need to ensure residents who chose to self-administer medications were evaluated at least quarterly to ensure their ability to do so safely was discussed with Staff 2 on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

1.RN will conduct a quarterly self medication assessment for resident #4 identifying their ongoing ability to self administer medications. 2. The nurse will provide assessment prior to admission if requested as well as quarterly. 3.On admission and quarterly. 4.RN

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 1 sampled resident (#1) who had PRN psychotropic medications. Findings include, but are not limited to: Resident 1 was admitted to the facility in 12/2023 with diagnoses including depression and anxiety. Review of the resident's 04/01/24 through 05/19/24 MARs and current physician orders revealed the following: * An order for alprazolam 1 mg tablet to be administered by mouth two times daily as needed for anxiety; and * The medication was administered 17 times. The MAR lacked resident-specific parameters for staff describing how the resident presented behaviors such as anxiety. There was no documentation of what non-pharmacological interventions were to be attempted prior to administration of the medication, and during interviews on 05/22/24 and 05/23/24, staff stated they were not aware of any non-pharmacological interventions to attempt prior to administering 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 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (ED) via telephone during the exit conference on 05/23/24. The findings were acknowledged. No further documentation was provided.

1. Provide redirection or less intrusive intervention prior to giving psychotropic medications. Staff to offer resident specific non pharmacologic interventions and redirection. Staff to document effectiveness prior to the utilization of a psychotropic medication. If medications were administered, staff will provide follow up reflecting effectiveness. 2. Education for all staff on redirecting residents when behaviors occur. Follow up by the med tech if the medications are administered for effectiveness. 3. Each occurrence. 4. Med Tech

Based on interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: During the relicensure survey, conducted 05/20/24 through 05/23/24, interviews with staff and residents were conducted and staffing schedules were reviewed. In an interview on 05/20/24, Staff 2 (Resident Services Director) reported the facility was unable to always staff to the level of the posted staffing schedule, but that when this occurred the vacancies were filled by one of four administrative staff. On 05/21/24 at 5:00 pm Staff 2 reported she was working as a caregiver from 2:00 pm to 6:00 pm to fill in for a caregiver who had called off. Staff 2 was observed conducting administrative work throughout the facility between 2:00 pm and 5:30 pm, when surveyors left the building. Throughout the survey multiple sampled and unsampled residents and staff reported that the facility was frequently understaffed. On 05/23/24 staffing schedules for the weeks of 05/05/24 and 05/12/24 were reviewed. Ten of the 14 days reviewed had one or more shifts that were not staffed to the staffing level determined by the facility to meet resident needs. The facility's failure to ensure it had a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of residents was discussed with Staff 2 on 05/23/24 and was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director) via telephone. The findings were acknowledged.

1.Daily review of the ABST. Sufficient number of caregivers to meet the 24hr schedule and unschedule needs of each resident. 2. Daily review of the ABST. 3. Daily at clinical review. 4.Executive Director.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 7, 13, 14 and 15) completed all required pre-service orientation training, 3 of 3 newly hired direct-care staff (#s 13, 14 and 15) completed all required pre-service dementia training, and 7 of 7 newly-hired and long term staff (#s 5, 6, 7, 8, 13, 14 and 15) completed the approved Home and Community Based Services (HCBS) course by 03/31/24. Findings include, but are not limited to: Staff training records reviewed on 05/21/24 at 8:30 am with Staff 4 (Business Office Director) identified the following: 1. There was no documented evidence Staff 7 (Housekeeping), Staff 13 (CG), Staff 14 (CG) or Staff 15 (MT), hired on 02/13/24, 01/31/24, 01/09/24, and 01/03/24, respectively, had completed the following required pre-service orientation topic: * Department approved infectious disease prevention training. 2. Staff 13, Staff 14 and Staff 15 lacked documented evidence of required pre-service dementia training. 3. Staff 5 (Maintenance Director), Staff 6 (Culinary Director), Staff 7, Staff 8 (Housekeeping), Staff 13, Staff 14 and Staff 15 lacked documented evidence of completing the required HCBS course by 03/31/24. The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities, and all staff completed required HCBS training by 03/31/24 was discussed with Staff 4 on 05/21/24, Staff 2 (Resident Services Director) on 05/23/24, and reviewed with Staff 1 (Executive Director) via telephone during the exit conference. The findings were acknowledged.

1. Staff 7, 13, 14 and 15 will complete pre service, 30 day competency, annual training,dementia training and HCBS by 7/21/24. 2. BOD will require certificate proof of completion. 3.  Upon hire for all new staff and ensure all existing staff obtain a certificate by July 21, 2024. 4. BOD

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 13, 14 and 15) had documented evidence of demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 4 (Business Office Director) on 05/21/24. The following was identified: Staff 13 (CG) hired 01/31/24, Staff 14 (CG) hired 01/09/24, and Staff 15 (MT) hired 01/03/24, lacked documented evidence they had demonstrated competency in all job duties, and had been trained in First Aid and abdominal thrust training within 30 days of hire. Staff 4 reported in an interview on 05/22/24 that competency checklists had not been completed for newly hired direct care staff, apart from medication pass duties for MTs. Staff 4 also reported the facility did not have a system in place for training and demonstrating competency in first aid and abdominal thrust. The need to ensure staff completed all required training and demonstrated competency within 30 days of hire was reviewed with Staff 4 on 05/22/24, Staff 2 (Resident Services Director) on 05/23/24, and during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

1.Staff 13, 14 and 15 will complete all 30 day competency by 7/21/24. 2. Upon hire, the business office director will secure certificates in staff files. 3. Upon hire and prior to expiration. 4. BOD

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to consistently provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire and life safety records were reviewed with Staff 5 (Maintenance Director) on 05/21/24 and 05/22/24. The facility provided documentation of one fire drill in the last six months, which occurred on 04/30/24. The facility was not relocating residents from the simulated fire area, therefore, there was no documentation of: * Escape route use; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * Number of occupants evacuated. In addition, there was no documentation of fire and life safety instruction for staff consistently being provided on alternate months. The need to conduct fire drills every other month and provide fire and life safety instruction to staff on alternate months was discussed with Staff 1 (Executive Director) on 05/21/24 and Staff 5 on 05/22/24. They acknowledged the findings.

1.Fire drills will be conducted every other month. Education will be in alternate months. 2. The Maintenance Director will conduct fire drills utilizing Westmont Senior Living form. 3. Every other month for fire drills and training on odd months. 4.Maintenance Director

Based on interview and record review, it was determined the facility failed to re-instruct residents at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: On 05/22/24, the surveyor discussed the facility's process and documentation for instructing residents on fire and life safety procedures with Staff 5 (Maintenance Director). Staff 5 reported he did not have documented evidence of annual fire and life safety instruction to residents. The need to ensure residents were re-instructed at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire was reviewed with Staff 2 (Resident Services Director) and Staff 5 on 05/23/24, and during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

1.Residents will be educated upon admission within 24 hrs of admit and annually. 2. Documentation of residents' fire education will be kept in the binder in the maintenance office. 3. Admission and annually 4. Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: Observations on 05/20/24 identified the following areas in need of cleaning or repair: * Handrails throughout the facility had patches of worn varnish, exposing bare wood; * Built-in bench surrounding entry living room had large areas of worn varnish and bare wood;    * Chairs in dining room had chips and gouges on wood surfaces;    * Double door in dining room leading to outside had black streaks and multiple paint scrapes; and    * Carpet outside Room 145 had a large black circular stain. The areas needing cleaning and repair were reviewed with Staff 5 (Maintenance Director) and Staff 2 (Resident Services Director) on 05/23/24, and during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

1. Wall patching, handrails, and built in bench have been repaired and restrained. Dining chairs wood surfaces scheduled to be repaired and restrained by 7/4/24. Exit door outside of the dining room has been cleaned and received paint touch up. Carpet entering apartment 145 has been shampooed and is now in presentable condition. All interior and exterior materials and furniture will be kept clean and in good repair. 2. The Maintenance Director will conduct a quarterly walk through of all interior and exterior materials and furniture ensuring all are to quality standards. 3. Quarterly and as needed. 4. The Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to: The facility was toured on 05/20/24. Resident unit windows on the second floor opened vertically, and windowsills were lower than 36 inches. The windows in common areas and resident rooms lacked a system which limited how much the windows could be opened to prevent accidental falls. The need to ensure operable windows were designed to prevent accidental falls was discussed with Staff 5 (Maintenance Director) and Staff 2 (Resident Services Director) on 05/23/24, and was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

1. Resident unit windows and common area windows that open vertically will have safety mechanisms installed that limits the amount of opening of the window eliminating falls. 2. During quarterly exterior walk through. Window clearance will be reviewed. 3. Quarterly and move out inspections. 4. Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters did not exceed 120 degrees Fahrenheit (F) when they were installed in locations that were subject to incidental contact by residents or with combustible material. Findings include, but are not limited to: On 05/20/24 at 4:15 pm Room 144, a one-bedroom unit, was observed to have a wall heater in the bedroom. The heater was located where a resident could come into incidental contact with it. When the heater was turned on and allowed to heat up, the metal surface of the heater reached 181.2 degrees F. In an interview on 05/22/24 Staff 5 (Maintenance Director) reported that 12 rooms in Wing E had this type of wall heater. The risk posed by the hot surface of the wall heaters was discussed with Staff 5 on 05/21/24, and with Staff 1 (Executive Director) on 05/21/24 and 05/22/24. They acknowledged the findings and deactivated the heaters until a long-term solution could be ascertained.

1. All wall heaters in wing E were disconnected immediately after discovery of temperatures exceeding 120 degrees. All discovered units contain a ptack unit which provides sufficient heating and cooling temperatures. 2. All wall heaters in wing E have been permanently disconnected. 3. Move out inspection to ensure the wall heater has stayed disconnected. 4. The Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure water temperatures in residents' units were maintained within a range of 110 and 120 degrees Fahrenheit. Findings include, but are not limited to: On 05/21/24, water temperatures in resident rooms 105, 215, and 237 measured 102, 103, and 108 degrees Fahrenheit, respectively. In an interview on 05/22/24, Staff 5 (Maintenance Director) reported that the facility was aware of low water temperatures in rooms 103, 105, 203, and 205, and "many years ago" a plumber had determined that the issue was related to the water being at the end of the line, related to the water heater, in this area of the facility. The need to ensure water temperatures in resident apartments were maintained within the required range was discussed with Staff 5 on 05/22/24, Staff 2 (Resident Services Director) on 05/23/24, and was reviewed during the exit conference on 05/23/24 with Staff 1 (Executive Director). They acknowledged the findings.

1. Facility will ensure resident Apartments  103, 105, 203, 205, 215 and 237 water temperatures are maintained between 110-120 degrees. 2. Water adjustment will be increased to ensure all listed above units reach temperature between 110-120 while ensuring all facility units do not exceed 120 degrees. 3. Quarterly during interior walk through as well as move in process. 4. The Maintenance Director

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 to provide security and to alert staff when residents exited the building. Findings include, but are not limited to: The building was toured on 05/20/24. Observations and interviews with staff 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 left the building. On 05/21/24, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 5 (Maintenance Director) and Staff 1 (Executive Director). They acknowledged the findings.

1. The Maintenance director implemented alarms on each existing door to the outside public which provides security and to alert staff of any traffic in or out of the building after busy hours. 2. Alert prompts staff of low battery which will be reviewed daily. 3. Prior to daily activation medication tech will sample door alarms ensuring alarms trigger. 4. Maintenance and Med Tech

The findings of the re-licensure survey, conducted 05/20/24 through 05/23/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 05/23/24, conducted 01/06/25 through 01/08/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation, interview, and record review conducted during a site visit on 02/21/24 and 02/22/24, it was confirmed the facility failed to have a service plan that reflects the resident's needs for 1 of 1 sampled resident (#4). Findings include, but are not limited to: On 02/22/24, CS observed the following: · Staff assisted Resident 4 with ambulation and bathroom assistance. · An erase board in the medication room indicated Resident 4 needed one-hour checks. During shift change from day shift to swing shift on 02/22/24, CS interviewed Staff 3 (CG), Staff 4 (CG), Staff 5 (CG), Staff 6 (CG), Staff 7(CG), and four additional unsampled staff who all indicated Resident 4 was not independent with transferring/ambulation, toileting, and bathing. Staff indicated Resident 4 was on frequent checks to assist with his/her toileting needs. During an interview on 02/22/24, Resident 5 indicated Resident 4's service plan had not properly reflected his/her needs. A review of Resident 4 service plan dated 01/20/24, indicated the following: · Receive one person assistance with bathing twice a week. · Independent with bladder management, sometimes wearing briefs and was independent with changing those. · Independent with transferring and mobility. A review of a temporary service plan (TSP) dated 12/10/24, indicated resident must have help with ambulation to the bathroom, bed, and wheelchair. An additional TSP on 01/10/24 indicated staff to encourage the resident to use call pendent for transfers. A review of the shower schedule indicated Resident 4 was to receive showers on Tuesdays and Thursdays. A review of Resident 4's shower sheets indicated from 01/20/24 through 02/21/24 the resident had been provided three out of eight showers on 01/29/24, 02/16/24, and 02/20/24. On 02/22/24, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The ED and RCC plan to have a care conference with residents' daughter to reflect the resident current care needs and a TSP will be created for resident in the meantime.

Based on observation, interview, and record review, conducted during a site visit on 02/21/24 through 02/22/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: On 02/22/24, CS observed the following: · The elevator was still broken. · Three CGs and two MTs working. · During lunchtime from 1:00 PM through 2:00 PM, one CG took a resident across the street to the hospital while the other two CG's were assisting residents up and down the elevator. The facility's posted staffing plan was observed and reviewed on 02/21/24, which included the need for the following staff: · Day shift: two MTs and three CGs · Swing shift: two MTs and three CGs · Night shift: one MT and two CGs During an interview on 02/21/24, Staff 1 (ED) indicated the facility's main elevator had been broken since the end of December 2023. There was a separate elevator located in the memory care. When residents in the assisted living needed to get between floors staff members had been assisting. There must be one staff member stationed on the first floor and one on the second floor. Due to this, s/he had added an additional staff member to assist. The additional staff had not been added to the schedule until 02/15/24. Staff 1 stated, "There had been a few residents who had fallen on the stairs, however it had been a direct result of the elevator being broken." A review of timecards for 02/05/24 through 02/06/24, indicated the facility had been staffed lower than the posted staffing plan listed above. A review of call light logs from 02/05/24 through 02/06/24, indicated 56 call light response times exceeded 15 minutes, and of those, 36 exceeded over 20 minute response times. A review of the staff schedule for 01/07/24 through 02/22/24 indicated the facility had not been consistently staffing an additional staff member to meet the additional needs with the broken elevator. A review of Resident 4s service plan dated 01/20/24, indicated resident was to received assistance with bathing twice a week. A review of the shower schedule indicated Resident 4 was to receive showers on Tuesdays and Thursdays. A review of Resident 4's shower sheets indicated from 01/20/24 through 02/21/24 the resident had been provided three out of eight showers on 01/29/24, 02/16/24, and 02/20/24. It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. On 02/22/24, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: Elevator is starting to be fixed on Thursday 02/22/24 and will continue into next week, the facility will continue to add an additional staff personal for assistance. There had only been one person who showered a resident, the RCC had that person train a few additional staff in the hopes of the resident receiving showers twice a week like their service plan stated. ED will continue to monitor call light response times and conduct additional training to staff within the next week. Staff have in place to give reminders to residents to take the elevator.

Based on observation and interview, conducted during a site visit on 02/21/24 and 02/22/24, it was confirmed the facility failed to keep all equipment necessary for the health, safety, and comfort of the resident in clean and good repair. Findings include, but are not limited to: On 02/21/24 and 02/22/24, CS observed the main elevator was broken and not in use. During separate interviews on 02/21/24 and 02/22/24, staff indicated the elevator was broken and had been since the end of December 2023. Staff 1 (ED) indicated there was a separate elevator located in the memory care. When residents in the assisted living needed to get between floors, staff members had to assist. It was confirmed the facility failed to keep all equipment necessary for the health, safety, and comfort of the resident in clean and good repair. On 02/22/24, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The elevator is starting to be fixed on Thursday 02/22/24 and will continue into next week.

Based on interview and record review, during a site visit conducted on 10/11/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: In separate interviews on 10/11/23, Staff 1 (ED) and Staff 2 (MC ED) stated the call light response time was between 5-10 minutes. CS was unable to obtain call light logs for April 2023. A review of the call light logs for 10/09/23-10/11/23 indicated 38 occurrences where response times exceeded 20 minutes. The staff schedule from 09/03/23-10/14/23 indicated multiple open uncovered shifts. It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. On 10/11/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The facility is constantly working on hiring staff, still using agency staff but trying to work on getting permanent staff. Will put more focus on call light response times on a daily and weekly basis.

Based on interview and record review, conducted during a site visit on 10/11/23, it was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but are not limited to: In an interview on 10/11/23, Staff 1 (Executive Director) stated the facility is using the ODHS ABST. S/He was unable to demonstrate how the hours were calculated to determine the facility's staffing levels. The facility is home to 58 residents. Staff 1 explained the facility had been staffing to two 12 hour shifts where two MT and two CG are scheduled for both shifts. Staff 1 stated s/he does not know how to convert their staffing levels using the acuity-based staffing tool. On 10/11/23, the facility's ABST was reviewed, and the staffing levels generated indicated the facility required six care staff on day shift, five care staff on swing shift, and two care staff on night shift. There were 39 residents' profiles that had not been updated quarterly. A review of the posted staffing plan indicated for day shift there are to be three CG and two MT, on swing shift there are two CG and two MT, and on NOC shift there are to be two CG and one MT. The posted staffing plan does not match the ABST nor the current facility staffing. It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. On 10/11/23, the findings were reviewed with and acknowledged by Staff 1.

Based on observation, interview, and record review, during a site visit conducted on 10/11/23, it was confirmed the facility failed to provide a lockable storage space. Findings include, but are not limited to: CS observed rooms 234, 240, 231, 217, and 244. One of five sampled apartments did not have a lockable storage space. A review of maintenance logs indicated several resident apartments that did not have a lockable storage space installed and/or a key had not been provided to the resident. In separate interviews on 10/11/23, Staff 1 (Executive Director) stated, "I believe maintenance has replaced all the locks about a month ago. Some locks were broken, and some apartments did not have a lock." Staff 3 (Maintenance) stated, "I installed locks in apartments that wanted them, most residents refused." It was confirmed the facility failed to provide a lockable storage space. On 10/11/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The facility has the locks and will install in all rooms. Should be completed "within the next two weeks."

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main kitchen in the Assisted Living on 08/17/23 revealed the following: * Walls and floors had an accumulation of black matter and/or dust throughout the kitchen; * Walk-in refrigerator and freezer units had food debris on the floors; * Doors and door jambs had paint chips and gouges; * Black debris and grease build-up was found inside the oven; * Multiple food items inside the walk-in cooler was not covered, labeled, or dated; * Ice machine lid was left unattended while the lid was left open; * There was a dented can in the dry storage; * A cutting board was observed with gray deep scores, creating an uncleanable surface; and *Several boxes of food were stored on the floor of the dry storage and freezer. Additionally, 2 out of 3 kitchen staff were sampled for evidence of current food handler cards. Staff 2 (Culinary Services Director) and Staff 3 (Cook), failed to have documented evidence of a food handler card. Staff 1 (Interim ED) reported Staff 2 and Staff 3 were pulled from the kitchen until they could complete the Oregon food handler course. On 08/17/23, the areas needing cleaning, repair and correction were reviewed with Staff 1. He acknowledged the findings.

1) Walls, floor, walk-in refrigerator and freezer units will undergo a professional deep clean to resolve cleanliness and food debris issues. Cleaning schedule and adjusting of staff will keep up with daily responsibilities. Culinary Director (CD) responsible for ongoing monitoring 2) Black debris and grease build-up of stove. Has been cleaned by kitchen crew. Cleaning schedules will be adhered to by cooks and CD responsible for ongoing monitoring. 3) Doors and door jambs paint chips and gouges being repaired by Maintenance Director and will be monitored by Culinary Director to ensure thet are maintained. 4) Some food item were not covered, labeled and/or dated. They will be inspected daily as staff have been retrained as to their responsibilities in performing these functions. Culinary Director responsible for ongoing monitoring. 5) Ice Machine left unattended with lid open. All staff who retrieves ice is being in-serviced on adhering to closing lid. Signage of instructions to be posted. This will be monitored by Culinary Director and cooks. 6) Dented can in dry storage. Damaged can and any future damaged cans are to be put out service immediately. Anyone unpacking food deliveries and CD responsible for monitoring. 7. Cutting board had deep gray scores creating uncleanable surface. Cutting board has already been replaced. CD will monitor for future wear and tear. 8. Several boxes of food were stored on the the floor in dry and freezer. Kitchen team has been retrained to keep them off the floor. CD and lead staff will review daily for compliance. 9.Evidence of Food Handling cards lacking for 2 out of 3 staff sampled. Staff was were pulled from kitchen. That was resolved for those 2 employees. System has been put in place so immediate access to proof of all staff who handle food is available for review. Business Office Director will maintain proof of completion.

The findings of the kitchen inspection, conducted 08/17/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 08/17/23, conducted 11/01/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and observation, it was confirmed that the facility failed to keep equipment clean and in good repair. Findings include: Compliance Specialist (CS) #1 observed on 04/11/2023 the facilities kitchen oven/stove is not working. Interview with Staff #2 on 04/11/2023 stated the facilities oven/stove is not working.  The part has been ordered and will be installed no later than 04/30/2023.  The facility has adjusted the menu during this time with hot food item that can be cooked with the other items in the kitchen.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 04/11/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 03/07/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview, observation, and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include: In an interview on 08/17/22, S1 stated that their current census is 53 residents. They have not implemented an ABST or other methods to determine staffing levels at this time. They are going to be using the ODHS tool, however, they have not entered any resident information. S1 states that there are multiple residents with outdated service plans, the facility is working on updating them to be able to input the proper information into the ABST. During an unannounced inspection on 08/17/2022, the Compliance Specialists (CS) did not observe a posted staffing plan. In review of the ODHS ABST tool on 08/17/22, the facility has not updated or entered any resident information into the tool. The above information was shared with Staff #1 on 08/17/22, who was in agreement with the findings. Facility Plan of Correction: Effective immediately, the Administrator will update resident service plans, contact, and consult with Department approved consultant, and begin using the ODHS ABST.

Based on observation and interview it was determined the facility failed to ensure infection control practices related to Oregon Health Authority recommended COVID-19 precautions were consistently implemented for all staff. Findings include, but are not limited to: Observations of common areas and the kitchen between 9/20/21 and 9/22/21 showed the following: * On 9/20/21 and 9/22/21 housekeeping staff were observed with masks below noses or chins while working on the second floor of the facility. * On 9/20/21 three kitchen staff were observed in the kitchen with cloth masks in place, one of which had stains/discoloration on the outside of the mask and one staff was observed with no mask in place. The staff were instructed to change their masks to disposable procedure masks and were observed to do so.  Additional observations of the kitchen approximately 60 minutes later showed staff had masks underneath noses or chins. * On 9/22/21 three kitchen staff were observed in the kitchen with no masks in place. The staff were again instructed to put on a disposable procedure mask. The staff were instructed to keep masks in place during their duties and that masks could be removed when in a break area for meals and to consume fluids. The staff were additionally reminded to wash or sanitize their hands each time after touching their masks. The need to ensure that disposable masks were in place and worn properly was discussed with Staff 1 (ED) on 9/20/21 and 9/22/21. Staff 1 acknowledged the findings.

1: ED has performed an all staff meeting on 10-6-2021 to ensure all are refreshed in Infection Control.   2: Infection control binder at front desk to ensure everyone has access to it. ED placed 3: " Please wear your mask at all times" signs all over the community. ED placed 4: Inservice on importance of Masks, hand hygiene and benefits from all.  All inservice done by ED and BOD 5. BOD or designee will perform random audits to ensure proper infection control is being followed 6 times a month. 6. BOD will report these audits to QAPI monthly for 3 months or until deficient practice is resolved. All residents, staff and visitors are at risk for this deficient practice.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 9/20/21 showed the following: * Multiple walls, doors and door frames had chips, dings, dirt/dust accumulation, gouges and/or spills; * Edges of the floor had black dust/dirt accumulation underneath the lower cupboards and at doorways; * Lower cupboards under the beverage station had exposed, untreated wood and missing laminate pieces; * Multiple cabinets and drawers had dirt, spills, splatters on the outside surfaces, and/or spills and debris inside the cupboards and drawers; * Refrigerator and freezer units had spills and debris under shelves, on the bottoms of the units, on the doors and vents; * Metal shelving units in the dry storage and refrigerator units had flaking/peeling paint hanging from several shelves, exposed rust, dark accumulation gathered on the shelves and caked on food debris; * Multiple areas of the kitchen floor were black with a dark accumulation around the edges of equipment and equipment legs; * Lights throughout the kitchen had splatters on the outside, debris inside the fixtures and the ceiling had orange/brown splatters over the prep area; * A large roll of butcher paper was stored directly on the floor with accumulated debris on the top of the roll; * A large, white cutting board surface on top of the canned good cart was black/gray in multiple areas; and * Drains under the sink and the dishwasher had food debris, accumulation of dark matter and garbage. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED) and Staff 11 (Culinary Services Director) on 9/20/21. The staff acknowledged the findings.

1: Racks have been ordered and will be replaced. Ordered on 9-10-2021. Awaiting arrival. ED ordered 2:Walls and paint have been deep cleaned and repainted by Kitchen staff. CD responsible for sign off. Will turn in an audit to QAPI 1x per month or until deficient practice is complete. 3: Inservice with Kitchen on nightly tasks held by CD on 11-01-2021 4: Kitchen cleaning task to ensure nightly routine is in place. 5: Culinary director will ensure weekly oversight of the kitchen to sign off on tasks. 6: Lower cabinets have been replaced.On order and awaiting arrival. ED ordered. 7. The Maintenance Director is responsible for ensuring all lights are taken down and cleaned. Will continue this practice monthly. 8. All floors were deep cleaned on 10-10-2021. Will be deep cleaned annually as well as needed. 9. CD will perform a monthly audit of all kitchen areas and ensure all surfaces are cleanable and in good repair. Will bring audits to QAPI monthly. All residents, staff and visitors are at risk for this deficient practice.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and failed to complete a 30 day evaluation for 1 of 1 sampled resident (#4) whose evaluations were reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in July 2021. The resident's move-in evaluation, dated 7/8/21, was reviewed. There was no documented evidence the following required elements were addressed prior to move-in: * Personality: including how the person copes with change or challenging situations; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature. The facility failed to complete an additional evaluation 30 days after admission. The need to ensure move in evaluations contain all required elements and 30 day evaluations were completed timely was discussed with Staff 1 (ED) on 9/22/21. She acknowledged the findings.

1-Nurse consultant team or their designee to perform audits on all resident assessments and service plans to include move in evals and 30 day evals with required elements. ED will bring to the monthly QAPI meeting . 2-ED created a tracker to ensure all assessments, change of conditions and necessary needs are met to ensure that the care plan states all needs will be met. Clinical team will review daily in standup. 3- ED will assign appropriate tasks found to be completed by clinical team members. 4- RSC or designee to read all TSP and CSP sheets at every change of shift to ensure they are met and signed off on by floor staff. 5-RSC or their designee will audit weekly to ensure all TSP and CSP are signed. Will bring all audits to QAPI monthly. 6-Required elements of 30 day and move-in evals have been updated by nurse consultant and Yardi creators for programs. 7- RSD will complete  a new evaluation for resident 4 and update SP accordingly.   8- Weekly clinical meeting to ensure all needs are met. All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#7) and failed to ensure quarterly evaluations were completed for 3 of 3 sampled residents (#s 5, 8 and 9). This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 12/2021 with diagnoses including chronic obstructive pulmonary disease and diabetes. The move-in evaluation failed to address the following elements: * Personality, including how the person copes with change or challenging situations; * Hearing, vision, speech, and assistive devices; * Ability to use call system; * Housework; * Transportation; * Recent losses; * Elopement risk or history; and * Alcohol and drug use. The need to address all required elements in the move-in evaluation was discussed with Staff 1 (ED) on 12/20/21. She acknowledged the findings. 2. Clinical records for Residents 5, 8, and 9 were reviewed and revealed there were no current quarterly evaluations. In an interview 12/20/21, Staff 1 (ED) reported she was unable to locate current quarterly evaluations for the residents. The need to complete resident evaluations every quarter was discussed with Staff 1 on 12/20/21. She acknowledged the findings.

-Nurse consultant team or their designee to perform audits on all resident service plans to include move in evals and 30 day evals with required elements. ED will bring to the monthly QAPI 1x per month or until deficient practice is complete. 2-ED created a tracker to ensure all assessments, change of conditions and necessary needs are met to ensure that the care plan states all needs will be met. Clinical team will review daily in standup. 3- ED will assign appropriate tasks found to be completed by clinical team members. 4- RSC or designee to read all TSP and CSP sheets at every change of shift to ensure they are met and signed off on by floor staff. 5-RSC or their designee will audit weekly to ensure all TSP and CSP are signed. Will bring all audits to QAPI monthly. 6-Required elements of 30 day and move-in evals have been updated by the nurse consultant team and Yardi creators for programs. All residents are at risk for this deficient practice

2. Resident 1 was admitted to the facility in February 2020 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 7/20/21, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas: * Foot wounds and slipper use; * Transfers, dressing and toileting; * Edema and weight changes; * Bathing/shower assistance twice a week; * Falls, spouse assisted transfers and safety interventions; and * Wheelchair and walker use. The need to ensure resident service plans were reflective of current care needs, provided direction to staff and were followed was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. They acknowledged the findings. 3. Resident 3 was admitted to the facility in April 2020 with diagnoses including diabetes and congestive heart failure. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 7/17/21, and temporary service plans dated 6/1/21 through 9/20/21 showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Dressing, grooming and toileting assistance; * Walker use; * Edema and weight changes; * Bathing/shower assistance twice a week; * Right side rail placement; and * Wheelchair and walker use. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed, reflective of residents' needs, provided clear direction regarding the delivery of services and/or was followed by staff for 3 of 4 sampled residents (#s 1, 3 and 4). Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in July 2021 with diagnoses of chronic pain and anxiety. Observations and interviews with staff and the resident were conducted during survey and identified that Resident 4 was independent with mobility and ADLs. The resident called for staff assist when s/he needed it. There was no documented evidence a service plan was completed at the time of the resident's admission to the assisted living facility from the memory care. The need to ensure service plans were completed prior to a residents move-in was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21.  They acknowledged the findings.

1 Nurse consultant team or their designee to perform audits on all resident service plans to include move in evals and 30 day evals with required elements. ED will bring to the monthly QAPI meeting   2-ED created a tracker to ensure all assessments, change of conditions and necessary needs are met to ensure that the care plan states all needs will be met. Clinical team will review daily in standup. 3- ED will assign appropriate tasks found to be completed by clinical team members. 4- RSC or designee to read all TSP and CSP sheets at every change of shift to ensure they are met and signed off on by floor staff. 5-RSC or their designee will audit weekly to ensure all TSP and CSP are signed. Will bring all audits to QAPI monthly. 6-Required elements of 30 day and move-in evals have been updated by nurse consultant and Yardi creators for programs. 7- RSD will complete new  service plans to ensure residents' current updated needs and preferences for residents 2,3 and 4. Resident 1 has been discharged.   8- Weekly clinical meeting to ensure all needs are met. All residents are at risk for this deficient practice

2. Resident 8 was admitted to the facility in 06/2020 with diagnoses including diabetes, chronic kidney disease, and decubitus ulcer. Resident 8's service plan dated 02/23/21, 12/01/21 through 12/20/21 MAR/TAR, and progress notes dated 11/20/21 through 12/20/21 were reviewed. Observation of and interview with Resident 8 and interviews with Staff 1 (ED) and Staff 22 (CG) were completed. The service plan was not reflective and did not provide instruction to staff in the following areas: * Side rails; * Heel wound; * Lower extremity edema; * Outside provider services for wound care and physical therapy; * Pain; * Preference to have all meals in room; * Use of electric wheel chair; and * ADL assistance for lower body dressing. On 12/20/21 the need to ensure service plans were reflective of residents'  current needs and status and provided clear direction to staff regarding the delivery of services was discussed with Staff 1. She acknowledged the findings. 3. Resident 5 was admitted to the facility in 11/2018 with diagnoses including dementia. a. The service plan available to staff and the survey team during the survey was last reviewed and updated on 02/25/21. The facility failed to review the service plan quarterly. b. Observations and an interview with the resident, interviews with staff, and review of the clinical record revealed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Current skin status and treatment; and * Discontinuation of Home Health services. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were updated at least quarterly was discussed with Staff 1 (ED) on 12/20/21. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and needs, provided clear direction regarding the delivery of services, and were updated quarterly for 3 of 3 sampled residents (#s 5, 8, and 9). This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in 12/2020 with diagnoses including Alzheimer's disease and stroke. Review of the resident's most recent service plan, dated 04/26/21, interviews with staff and the resident, and observations of the resident during survey revealed the service plan was not reflective in the following areas: * History of stroke with left-sided hemiparesis; * Home health services; and * Preference for female caregivers. In an interview on 12/20/21, Staff 1 (ED) reported she was unable to locate a current service plan for the resident. The need to ensure service plans were reflective of residents' current needs, provided clear direction to staff, and were completed quarterly was discussed with Staff 1 on 12/20/21. She acknowledged the findings.

-Nurse consultant team or their designee to perform audits on all resident service plans to include move in evals and 30 day evals with required elements. ED will bring to the monthly QAPI 1x per month or until deficient practice is complete. 2-ED created a tracker to ensure all assessments, change of conditions and necessary needs are met to ensure that the care plan states all needs will be met. Clinical team will review daily in standup. 3- ED will assign appropriate tasks found to be completed by clinical team members. 4- RSC or designee to read all TSP and CSP sheets at every change of shift to ensure they are met and signed off on by floor staff. 5-RSC or their designee will audit weekly to ensure all TSP and CSP are signed. Will bring all audits to QAPI monthly. 6-Required elements of 30 day and move-in evals have been updated by the nurse consultant team and Yardi creators for programs. All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed.  Findings include, but are not limited to: Residents 1, 3 and 4's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. They acknowledged the findings.

1- Facility will ensure a Service planning team is present for new changes and existing plans for resident 3, 4 as 1 was discharged. 2- Team will consist of ED/PD, RSD, RSC, resident and family. Floor staff will sign new updated forms to acknowledge that needs are met. 3-Nurse consultant or their designee to perform audits on all resident service plans to include move in evals and 30 day evals with required elements and signatures of the service planning team. ED will bring to the monthly QAPI meeting until deficient practice is resolved. All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to ensure a service planning team, consisting of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with, or who was going to provide services to, the resident, was involved in creating service plans for 3 of 3 sampled residents (#s 5, 8, and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: Residents 5, 8, and 9's most recent service plans lacked documentation a service planning team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a service planning team was discussed with Staff 1 (ED) on 12/20/21. She acknowledged the findings.

- Facility will ensure a Service planning team is present for new changes and existing plans for residents. 2- Team will consist of ED/PD, RSD, RSC, resident and family. Floor staff will sign new updated forms to acknowledge that needs are met. 3-Nurse consultant or their designee to perform audits on all resident service plans to include move in evals and 30 day evals with required elements and signatures of the service planning team. ED will bring to the monthly QAPI meeting until deficient practice is resolved. All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, and the condition was monitored to resolution at least weekly for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who experienced changes of condition.  Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in February 2020 with diagnoses including dementia. The resident's 7/20/21 service plan, 6/2/21 through 8/13/21 progress notes, temporary service plans and physician communications were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Falls; * Hospitalization; * Weight fluctuations; * Neck pain; * Swollen knee; and * New medications and medication changes. The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed  with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. The staff acknowledged the findings. 2. Resident 3 was admitted to the facility in April 2020 with diagnoses including diabetes and depressive disorder. The resident's 7/17/21 service plan, 6/27/21 through 8/23/21 progress notes, temporary service plans and physician communications were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Weekly weights and weight fluctuations; * Low blood pressures; * Hip pain; and * New medications and medication changes. The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) on 9/21/21. She acknowledged the findings. 3. Resident 2 was admitted to the facility in August 2015. Resident 2's progress notes dated 6/15/21 through 9/19/21 and an incident report dated 6/11/21 identified the following change of condition: The resident sustained a skin tear to the right shin on 6/11/21. S/he was sent to the ER on 6/15/21 with complaints of pain to the right leg. The resident returned and was started on an antibiotic for an infection of the leg wound. There was no documented evidence the facility determined and documented what action or interventions were needed for the resident's wound and had communicated  to staff on each shift. There was no documented evidence the resident's medical condition related to the infection was monitored weekly to resolution. The need to ensure the facility had a system for documenting changes of condition and monitoring until resolved was reviewed with Staff 1 (ED) on 9/22/21. She acknowledged the findings. 4. Resident 4 was admitted to the facility in July 2021 with diagnoses including anxiety and chronic pain. Resident 4's record was reviewed for short term changes of condition that occurred  7/12/21 through 9/19/21 and the following were identified: * New admission to the facility; * Lower extremity cellulitis with antibiotic treatment; and * Medication error. There was no documented evidence the changes of condition were evaluated or monitored through resolution. The need to monitor short term changes of condition to resolution and evaluate interventions was reviewed with Staff 1 (ED) on 9/21/21. She acknowledged the findings.

1- Resident 1 is discharged. ED and the facility team reviewed a 24 hour process. 2-ED Held in service on short term COC and what to look for, charting and adding to TSPS. 3- RSD or designee will audit the 24 hour book 5 days a week to ensure all short term COC are placed on alert and TSP on alert. 4- Clinical services team will review documentation weekly to ensure information is documented. WIll bring audits to monthly QAPI meeting 5-RSD will ensure that the completion of the triple check system to ensure all short term COC are noted and charted appropriately. 6- RSD or designee will alert RN of any short term COC that is not resolving to trigger a comprehensive COC. 7- For residents 2,3,4 the last 2 weeks were reviewed to rule out any short term change of conditions. Any changes of condition identified will be further evaluated. 8- Nurseconsultant team will do a random 5 resident charts  sample audit of current residents to ensure COC are captured if needed and steps followed. Results will be brought by ED to QAPI monthly meeting.   All residents are at risk for this deficient practice

2. Resident 8 was admitted to the facility in 06/2020 with diagnoses including diabetes, chronic kidney disease, and anxiety disorder. The resident's 02/23/21 service plan, 11/20/21 through 12/20/21 progress notes, temporary service plans, and physician communications were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution: * Hypoglycemic event; * Missed psychotropic medication; and * Increase in Humalog insulin to 40 units three times a day with meals. The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly was discussed  with Staff 1 (ED) on 12/20/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were monitored and progress was documented at least weekly through resolution for 2 of 2 sampled residents (#s 8 and 9) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in 12/2020 with diagnoses including Alzheimer's disease and stroke. Review of the resident's clinical record, including the current service plan dated 04/26/21, temporary service plans, hospital discharge records, progress notes, and home health visit notes, in addition to interviews with staff and the resident, revealed the following: * Resident 9 was sent to the hospital 11/16/21 and diagnosed with a stroke; * S/he returned from the hospital 11/17/21 with hemiparesis of the left side; * Occupational and physical therapies were initiated 11/22/21 and 11/26/21, respectively; * A temporary service plan dated 11/17/21 directed staff to check on the resident frequently, ensure the call button was within his/her reach at all times, and toilet the resident during the night; and * One progress note, dated 12/01/21, referred to the resident returning from the hospital, wanting meals in his/her room, staff assisting with toileting and nighttime needs, and assisting him/her to meals and back. There was no documented evidence the resident was being monitored for signs or symptoms of stroke or that his/her hemiparesis was being monitored by staff. The need to monitor short-term changes of condition through resolution with at least weekly documentation was discussed with Staff 1 (ED) on 12/20/21. She acknowledged the findings.

1- ED and the facility team reviewed a 24 hour process. 2-ED Held in service on short term COC and what to look for, charting and adding to TSPS. 3- RSD or designee will audit the 24 hour book 5 days a week to ensure all short term COC are placed on alert and TSP on alert. 4- Clinical services team will review documentation weekly to ensure information is documented. WIll bring audits to monthly QAPI meeting 5-RSD will ensure that the completion of the triple check system to ensure all short term COC are noted and charted appropriately. 6- RSD or designee will alert RN of any short term COC that is not resolving to trigger a comprehensive COC. 7- Nurseconsultant team will do a random 5 resident charts  sample audit of current residents to ensure COC are captured if needed and steps followed. Results will be brought by ED to QAPI monthly meeting.   All residents are at risk for this deficient practice

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 1 of 2 sampled residents (#1) who experienced a significant change. Findings include, but are not limited to: Resident 4 was admitted to the facility in February 2020 with diagnoses including dementia and congestive heart failure.   Progress notes and physician communications dated 6/14/21 through 9/14/21, and interviews with care staff on 9/14/21 and 9/15/21 indicated the resident required one person assistance with care. The resident had a decline in July 2021 when s/he experienced a fall with fracture. The resident was noted to have intermittent edema and fair meal intake. a. Review of the resident's weekly weight records from 3/1/21 through 9/20/21 showed the following: * On 6/22/21 and 6/29/21 the resident's weight was noted at 125 lbs. * The resident's weights in May 2021 and July 2021 were between 100 and 102 pounds. * The resident experienced a 24 lb weight gain from 5/25/21 to 6/22/21, which constituted a 23% weight gain in one month. * The resident experienced a 22.2 pound weight loss from 6/22/21 to 7/13/21 which constituted a 17.26% weight loss. An RN assessment dated 7/24/21 indicated there was a 22.2 lb weight loss and a reweigh would be obtained. There was no additional information regarding the weight loss. An additional RN assessment dated 8/15/21 indicated staff were asked to "evaluate the 6/21 weight as they seemed to be outliers." There was no additional documentation regarding the potentially inaccurate weights. Observations of the resident on 9/20/21 and 9/21/21 showed the resident ate both in the dining room and in her/his apartment with their spouse. The resident did not independently seek out food or fluids during observations but was able to feed herself/himself without assistance once items were provided. The resident's intake was approximately 50% of the items provided, though s/he did eat 100% of pudding and yogurt that was offered. The facility failed to ensure an RN assessment was completed timely for the potential weight loss and gain with documented findings, resident status and interventions made as a result of the assessment. b. On 8/4/21 skilled nursing through hospice was completed for pressure wounds to the resident's feet and daily treatment direction was provided. Ongoing hospice visits were to occur 1-3 times per week for wound care. Hospice notes indicated the areas were stage 2 pressure wounds. An RN assessment dated 8/15/21 indicated it was a change of condition for "pressure injuries." The assessment indicated during a record review the RN came across the hospice note from 8/4/21. The RN was not previously made aware of the pressure injuries and requested additional information from hospice. Measurements of the left and right foot were documented and reference made to the treatment plans established by hospice. The facility failed to ensure an RN assessment was completed timely for the pressure wound which documented findings, resident status and interventions made as a result of the assessment. The need to ensure an RN assessment was completed timely, related to significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. The staff acknowledged the findings. The need to ensure a thorough RN assessment was completed timely was discussed with Staff 2 (RN) on 9/22/21, via phone. No additional information was provided.

1- Resident 1 was discharged. 2- ED has completed an audit of RN COC completed for the last 30 days to ensure that the facility staff have reviewed the assessments and updated the service plans accordingly. 3-RSD or designee will update service plans based on the RN COC assessments. 4- RN is adding to her COC assessment that Service plans updates will be completed by needed staff. RN will review COC service plans monthly to ensure proper updates are completed. Report results to ED for completion and Audit findings for QAPI meeting. All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure documentation of visits were maintained in the residents' records, and that recommendations were implemented for 2 of 3 sampled residents (#s 1 and 4) who were receiving home health services from outside providers. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in February 2020 with diagnoses including dementia and congestive heart failure. During the acuity interview on 9/20/21, Resident 1 was identified as receiving outside provider services related to hospice and wound care. Review of the record indicated the resident sustained a fall with a hip fracture on 7/16/21. The resident returned from the hospital on 7/22/21 with hospice services in place.  The resident was noted to have bilateral wounds to her/his feet which were discovered on 8/4/21, hospice began treatment of the wounds. Hospice nursing visits were to occur 1-3 times per week. Hospice nursing visit notes were not consistently documented and/or recommendations were not implemented as follows: * There were no visits documented from 7/16/21-7/31/21, nursing visits were documented on two occasions between 8/1/21-8/31/21 and two occasions between 9/1/21 and 9/20/21; * Nursing recommendations on 8/4/21 indicated staff were to remind the resident's spouse "not to use slippers that created wounds;" and * Nursing recommendations on 8/17/21 indicated the facility could provide pressure relief boots and staff were not to put slippers on the resident's feet. There was no evidence the recommendations were implemented and/or communicated to staff.   The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. The staff acknowledged the findings. 2. Resident 4 was admitted to the facility in July 2021. During the acuity interview on 9/20/21, the resident was reported to receive nursing services from an outside service provider for recurrent lower extremity cellulitis. Review of Resident 4's 7/13/21 through 9/20/21 facility record revealed the following home health nursing communications were not reviewed for follow up and were not added to the service plan and communicated to staff: * 7/28/21 "Keep legs clean and dry with compression (medigrips G) in place from foot to knee bend;" * 7/31 "Leave stockinet in place till next visit;" * 8/9/21 "Reinforce or change dressing if wet, soiled or damaged. Minimal tape usage. Xeroform to open areas only;" and * 8/17/21 "Encourage resident to wash and lotion legs two times a day." On 9/21/21 Staff 1 (ED) reported the resident was independent with all lower extremity care and treatments. The failure of the facility to coordinate care with outside providers, ensure recommendations were reviewed, recommendations were added to the service plan and communicated to staff was discussed with Staff 1 on 9/22/21. She acknowledged the findings.

1- Resident 1 is discharged. 2- Resident number 4 ED has reviewed and noted all current outside provider documentation and updated the chart accordingly. 3-Outside provider documents are being reviewed in standup daily. RSD or designee will note them daily and follow up with documentation accordingly, to include alert charting and TSP. 4- Nurse consultant team will perform a 5 resident chart audit of outside documentation to ensure orders are in place and report monthly to ED for QAPI. All residents are at risk for this deficient practice

2. Resident 3 was admitted to the facility in April 2020 with diagnoses including neuropathy and chronic pain.   The resident's signed physician orders dated 9/4/21 and 9/16/21 included the following orders: * Tramadol 50 mg every six hours PRN for pain; and * Hydrocodone/APAP 5-325 mg every eight hours PRN for pain. The resident's Controlled Substance Disposition logs and MARS, reviewed from 8/1/21 through 9/20/21 showed the following: * On 8/2/21 and 8/11/21 Tramadol doses were signed out on the disposition log, but were not on the MAR; * An 8/3/21 Tramadol dose was signed out on the MAR, but was not on the disposition log; * A partially filled out line on the disposition log indicated one Tramadol was given but contained no date, time or signature of the staff that signed out the medication; * A 9/14/21 Tramadol dose was signed out on the MAR, but was not on the disposition log; * A medication card for acetaminophen/codeine 300-30 mg every four hours PRN for pain was located in the medication cart. The medication was discontinued on 6/3/21, disposition logs showed the medication was last given on 6/2/21. The card and log gave no indication the medication was discontinued. Comparison of the medication dosing cards to the disposition logs, showed the amount of medication left was reflected accurately on the log. The need to ensure narcotic disposition logs accurately reflected the medications administered and that discontinued medications were removed from the medication cart and destroyed in a timely manner was discussed with Staff 1 (ED) and Staff 3 (LPN). Staff 1 indicated normally medications were destroyed within 72 hours but sometimes there was a delay. Staff 1 had no other information related to the delay in destroying the acetaminophen with codeine. The staff 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 and to ensure discontinued controlled substances were disposed of in a timely manner for 2 of 3 sampled residents (#s 3 and 4) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted in 2021 and had diagnoses which included chronic pain. Resident 4 had an order for Oxycodone (narcotic analgesic) 5 mg, one tablet every six hours for pain management. Resident 4's Controlled Substance Disposition Logs and MARs, reviewed from 9/1/21 - 9/20/21, revealed two occasions when staff signed on the MAR that the Oxycodone was administered. However, the drug disposition log lacked documentation that the resident received the medication. On 9/7/21 Oxycodone was signed out on the drug disposition log five times. The MAR documentation showed the medication was administered four times that day. The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) on 9/21/21. She reviewed the documentation and acknowledged the discrepancies.

1-Resident 3, and 4 reviewed current orders and documentation to ensure sufficient controlled substances to meet the orders. 2- ED held inservice to ensure all med techs are following med room processes adequate to ensure.      3- RSD or designee will perform a narcotic count audit monthly to include a 5 charts  resident sample matching administration to MAR of narcotic administration record. will bring to QAPI 1x per month or until deficient practice is complete. 4-RSD or designee to audit bi monthly the narcotic drawers to ensure all medications are active orders and destroy  meds per policy that are not. All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 3 of 3 sampled residents (#s 1, 3 and 4) who had documented medication and/or treatment refusals. Findings include, but are not limited to: Resident 1, 3 and 4's 8/1/21 through 9/20/21 MARs were reviewed. The residents' records showed multiple medication and/or treatment refusals. There was no documented evidence the facility notified the physician/practitioner each time the resident refused to consent to the orders. On 9/22/21, the need to ensure the facility notified physicians/practitioners of medication and/or treatment refusals was discussed with Staff 1 (ED). She acknowledged the findings.

1- Resident is discharged 2- RSD or designee for residents 3and 4 will review last 30 days of med administrations and refusals and report to PCP 3- ED sent a fax to every PCP regarding notification of refusals. RSD will update info orders to include refusals. 4-RSD will audit 5 of resident population of monthly and report refusals to PCP and bring results to QAPI 1x per month or until deficient practice is complete All residents are at risk for this deficient practice

3. Resident 4's 9/1/21 through 9/20/21 MARs were reviewed and revealed the following orders: * Milk of Magnesia two times daily as needed for constipation; * Docusate Sodium every day as needed for constipation; * Bisacodyl Suppository every day as needed for constipation; * Miralax every day as needed for constipation; and * Senna/Docusate twice daily as needed for constipation. The MAR lacked clear direction and instruction to staff regarding which medications to administer first, second, third etc. for constipation, or when to notify the health care provider if ineffective. The need to ensure MARs included clear parameters and direction to staff for medication administration was discussed with Staff 1 (ED) on 9/22/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident-specific parameters for PRN medications for 3 of 4 sampled residents (#1, 3 and 4) whose medication records were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in February 2020 with diagnoses including dementia. Review of the resident's 6/2/21 through 8/13/21 progress notes, physician communications, and the 8/1/21 through 9/20/21 MARs showed the following: * Lorazepam Intensol 2 mg/ml, give 0.25 ml to 1.0 ml every four hours, PRN anxiety. There were no parameters to direct staff on what dose to give from the dosage range listed and no direction on what the resident's anxiety looked like. * Morphine Sulfate 20 mg/ml give 0.25 ml to 1.0 ml every 30 minutes, PRN for pain and shortness of breath. There were no parameters to direct staff on what dose to give from the dosage range listed. * Morphine, Hydrocodone and Tylenol were ordered PRN for pain. There were no parameters to direct staff which pain medication to give to the resident and in what order. The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (ED) and Staff 3 (LPN) on 9/21/21. The staff acknowledged the findings. 2. Resident 3 was admitted to the facility in April 2020 with diagnoses including diabetes and congestive heart failure. Review of the resident's 6/27/21 through 8/23/21 progress notes, physician communications and the 8/1/21 through 9/20/21 MARs showed the following: * A blood sugar of 11 was noted on 8/8/21. There was no other documentation regarding the blood sugar to indicate if it was an error or an accurate reading; * Multiple blanks were noted on the MAR in August 2021 and September 2021 related to Levothyroxine, Metformin, Simvastatin, Gabapentin, Basgalar insulin, Trazodone and a gummy vitamin; * Acetaminophen, Tramadol and Hydrocodone were ordered PRN for pain. There were no parameters for staff on which of the pain medications to give first and in what order; * Milk of Magnesia PRN for constipation. There was no information for staff on when to start the medication; and * An order to monitor the resident for low blood pressure twice a day. There was no information directing staff what blood pressure readings to watch for. The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (ED) on 9/21/21. She acknowledged the findings.

1-Resident 1 has discharged 2-Resident 3 and 4 med administration records will be  reviewed and all needed parameters put in place by RSD or designee. 3-RSD or designee review all residents medications and treatments requesting needed parameters from PCP. RSD or designee will implement PRN parameters as directed by regulation. 4- Nurse consultant team will complete a random audit monthly to ensure all medication parameters are in place. Results will be brought to the monthly QAPI meeting until deficient practice is corrected. All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's anxiety had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 1 of 2 sampled residents (#4) who were prescribed PRN medication for anxiety. Findings include, but are not limited to: Resident 4 was admitted to the facility in July 2021 with diagnoses including anxiety and post traumatic stress disorder. Review of the resident's 9/1/21 through 9/20/21 MAR and 8/24/21 physician's orders showed the following psychotropic medication: * Lorazepam 0.5 mg (a psychotropic medication), one tablet twice a day as needed for anxiety. The facility administered the Lorazepam to the resident on nine occasions between 9/1/21 and 9/20/21. The MAR did not contain resident specific parameters for staff describing how the resident expressed anxiety. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medications. The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and that non drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (ED) on 9/21/21. She acknowledged the findings.

1- Resident number 4 medications will be reviewed by the RSD and proper non pharmacological interventions will be added to try prior to administration of psychotropic medications. 2-ED performed inservice on non drug interventions and individual interventions for residents to ensure proper knowledge of psychotropic medications 3-RSD of designee will do a full resident audit and add no drug interventions for each resident for the MAR and service plan. 4- Nurse consultant team will do a 5 charts or resident audit of residents on psychotropic medications to ensure all non pharmacological interventions are in place on the MAR and service plan. ED will bring it to the QAPI meeting until deficient practice is corrected.

Based on interview and record review, it was determined the facility failed to ensure that 2 of 3 newly-hired employees (#s 5 and 9) had completed pre-service orientation or dementia care training prior to assuming their job duties. Findings include, but are not limited to: Staff training records were reviewed on 9/21/21. The following was noted: 1. Staff 9 (CG) was hired 7/29/21. There was no documented evidence Staff 9 completed the following training requirements: * Standard precautions for infection control; * Fire safety and emergency procedures; and * Pre-service dementia training. 2. Staff 5 (MT) was hired 6/29/21. There was no documented evidence Staff 5 completed the following training requirements: * Fire safety and emergency procedures; and * Pre-service dementia training. The need to ensure documentation of completed pre-service training was reviewed with Staff 1 (ED) and Staff 4 (Business Office Director) on 9/21/21. Staff  acknowledged the lack of training documentation.

1-Staff 5 and 9 will complete their preservice training. 2- BOD or designee will do a full staff audit of current employees to ensure all preservice and dementia 6 hour training not completed are identified 3- All staff identified in this audit will complete all necessary training 4- ED will audit all training of staff hired to ensure proper training has been completed and brought to the QAPI meeting until deficient practice is corrected. All residents are at risk for this deficient practice

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 5, 9 and 10) had documented demonstration of competency in all required areas and First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Review of the facility's training records on 9/21/21 indicated the following: 1. Staff 10 (CG), hired 1/28/21, lacked documented evidence of competency completed within the first 30 days of hire in the following areas: * Identification, documentation and reporting of changes of condition; * General food safety, serving and sanitation; and * First Aid and abdominal thrust training. 2. Staff 9 (CG), hired 7/29/21, lacked documented evidence of competency completed within the first 30 days of hire in the areas of : * The role of service plans in providing individualized resident care; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First Aid and abdominal thrust training. 3. Staff 5 (MT), hired 6/29/21, lacked documented evidence of competency completed within the first 30 days of hire in the areas of: * The role of service plans in providing individualized resident care; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First Aid and abdominal thrust training. The need to document demonstrated competency in job duties and complete First Aid and abdominal thrust training within 30-days of hire was discussed with Staff 1 (ED) and Staff 4 (Business Office Director) on 9/21/21. They acknowledged the findings.

1-Staff 5, 9 and 10 will complete their 30 day hire competency training. 2-BOD or designee will do a full staff audit of current employees to ensure all 30 day training not completed are identified 3- All staff identified in this audit will complete all necessary training 4- ED will audit all training of staff hired to ensure proper training has been completed and brought to the QAPI meeting until deficient practice is corrected. 5- CPR and abdominal thrust  training held on 10-15. All residents, staff and visitors are at risk for this deficient practice.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 20, 21, and 24) demonstrated competency of skills in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed on 12/20/21. There was no documented evidence Staff 20 (CG), Staff 21 (MT), and Staff 24 (MT), hired 11/08/21, 11/15/21, and 10/28/21, respectively, had completed one or more of the following required competencies: * The role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First aid/abdominal thrust. The need to ensure there was documented evidence all direct care staff demonstrated competency in all assigned job duties within 30 days of hire, including first aid/abdominal thrust, was discussed with Staff 1 (ED) on 12/20/21. She acknowledged the findings.

1-Staff to complete their 30 day hire competency training. 2-BOD or designee will do a full staff audit of current employees to ensure all 30 day training not completed are identified 3- All staff identified in this audit will complete all necessary training 4- ED will audit all training of staff hired to ensure proper training has been completed and brought to the QAPI meeting until deficient practice is corrected. All residents, staff and visitors are at risk for this deficient practice.

Based on interview and record review, it was determined the facility failed to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation. Findings include, but are not limited to: Fire and life safety training and fire drill records were reviewed with Staff 1 (ED) and Staff 14 (Maintenance Director) on 9/21/21.  The following was identified: * No documented evidence the facility was providing fire and life safety instruction to staff on alternating months from fire drills; * No documentation of escape route used; * No documentation of problems encountered and comments relating to residents who resisted or failed to participate in the drills; * No documentation of the evacuation time period needed; * No documentation of the number of occupants evacuated; and * No documented evidence of alternate routes being used during fire drills. The need to complete life safety training on alternate months and ensure fire drill documentation contained all required components was discussed with Staff 1 (ED) and Staff 14 (Maintenance Director) on 9/21/21. They acknowledged the findings.

1-Reviewed and updated policy to ensure required need for staff education on alternating month during fire drills 2- Fire Drill tool to include all necessary information needed on form. 3-ED will audit FLS binder monthly to ensure fire drills and education are done according to regulation. 4-Bring to QAPI meeting until deficient practice is corrected. All residents, staff and visitors are at risk for this deficient practice.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair. Findings include, but are not limited to: Observations of the patio and pathways on 9/20/21, showed there were multiple drop-offs of 2-4 inches along pathway edges and sitting areas in the patio area. Additionally, one section of concrete in the front pathway was lifting which created an uneven surface and potential tripping hazard. The need to ensure pathways in the resident courtyard did not have potential safety hazards was discussed with Staff 1 (ED) on 9/20/21. She acknowledged the findings.

1-MD and ED did a full exterior walk through identifying areas in concrete needing fixed and drop off areas. 2-Landscapers will fill drop offs with gravel on 10-20-21 3-Concrete has been fixed by the MD and team to ensure safe height. 4-MD or designee will exterior walk through monthly and bring results to QAPI meeting until deficient practice is corrected. 5-Any urgent need for ED to be fixed immediately.    All residents, staff and visitors are at risk for this deficient practice.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to: Observations of the facility on 9/20/21 and 9/21/21 showed the following areas in need of cleaning or repair: * Multiple walls, doors and/or door frames had scrapes, splatters/drips or gouges; * Multiple black, orange and white stains of varying sizes were noted to carpets in common areas and hallways on the first and second floor; * Multiple sections of carpet were noted to be extremely frayed and/or pulling away from the adjoining laminate floor in multiple areas throughout both floors of the facility; * A white substance was noted along the handrail near the upstairs activity area; * The oven in the activity area had debris and spills along the inside of the door and the bottom of the oven; * Utility sink in the upstairs laundry room had debris, dark stains and gray accumulation at the edges; * Room 212 inner door frame was pulling away from the wall; * Cobwebs, dead insects and black accumulation was noted to hallway and activity room windows on the second floor; * A long row of cupboards in the dining room was noted to have spills and stains on the cupboard doors and untreated surfaces where missing laminate was noted;   * Elevator walls were scraped and gouged and the flooring was gouged; and * The baseboard near the first floor laundry was pulling away from the wall and carpet baseboard pulling away near room 241 E. The areas in need of cleaning and repair were shown to and discussed with Staff 1 (ED) and Staff 14 (Maintenance Director) on 9/21/21. The staff acknowledged the findings.

1-MD and ED did a full facility walk through identifying areas in need of fixing to ensure they have cleanable surfaces. 2-MD team has started painting, carpet repairs and transitions being placed. 3- Housekeeping team will go through to include deep cleaning of areas. 4-MD wll perform a facility walk through audit to ensure cleanable surfaces in good repair and free from debris. 5-MD will bring all audit tools to the QAPI meeting until deficient practice is corrected. All residents, staff and visitors are at risk for this deficient practice.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 252, C 260, C 262, C 270, and C 372.

1- ED to reinspect all areas of deficant practice to ensure POC is being followed. 2- ED to ensure QAPI in place to be ready for reinspection and passing on survey.

The findings of the re-licensure survey, conducted 9/20/21 through 9/22/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit survey to the re-licensure survey of 09/22/21, conducted 12/20/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 09/22/21, conducted on 03/09/22, are documented in this report.  It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services.