Azalea Gardens Senior Living

The findings of the kitchen inspection, conducted 05/13/24 through 05/14/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 05/14/24, conducted 09/09/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 05/14/24, conducted 02/05/25, 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. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the third revisit to the kitchen inspection of 05/14/24, conducted on 06/17/25, 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 facility was found to be in substantial compliance.

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen and memory care kitchenette on 05/13/24 and 05/14/24 showed the following areas needed cleaning or repair.Main Kitchen:* Drips, splatters and/or debris were observed inside cupboards, under shelves, on top of dry goods, inside drawers, on the ceiling and on the walls throughout the kitchen and dry storage;* A broken light cover was noted near the tray line, other light covers had debris and dead insects inside and missing covers were noted to the lights in the dry storage;* Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment and at the door edges. Several sections of flooring around the center island were heavily discolored with a black/brown haze;* Shelving in multiple refrigerators and/or freezer units had spills, debris, white accumulation with dangling pieces, rust and chipped/peeling shelf coating;* Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board, bubbling paint;* Chipped laminate was noted on counter edges of the center island, the back splash was pulling away from the wall along the back counter, the counter near the back corner was pulling apart at the seam; * Debris and standing water were located in the drain under the sink as well as black stains along the interior walls and a strong sour odor; * The ice machine had spills and debris on the lower vent slats, broken and missing slats were noted as well;* Metal shelves throughout the kitchen had debris, drips and/or spills;* Two cutting boards were worn with numerous grooves;* Four large plastic pitchers were stained brown and had scrapes on the interior;* Debris, spills and stains in cupboard drawers and on shelves in the dining room drink station;* Scoop handles were extremely worn, scratched and gouged;* Large amounts of debris were noted underneath the stove on an exposed shelf area. The ovens did not have a cover piece in place along the bottom as it impeded the opening and closing of the oven doors;* Numerous open packages were noted in the dry storage area including cake mix, sugars, flour, biscuit mixes and breadcrumbs;* Cobwebs, dust and dead insects were noted in the windowsill, the screen to the open window had a thick layer of dust and debris on it; and* Food splatters/spills were noted on the underside of the small stand mixer.The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Executive Director) and Staff 2 (Dietary Manager) on 05/14/24. The staff acknowledged the findings.
Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the main kitchen on 09/09/24 showed the following areas needed cleaning or repair.* Drips, splatters and/or debris were observed inside cupboards, under shelves, inside drawers, and on the walls throughout the kitchen and dry storage;* A broken light cover was noted near the tray line, other light covers had debris and dead insects inside and missing covers were noted to the lights in the dry storage;* Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment and at the door edges. Several sections of flooring around the center island were heavily discolored with a black/brown haze and multiple seams were cracked or pulling apart;* Shelving in multiple refrigerators and/or freezer units had spills, debris, white accumulation with dangling pieces, rust and chipped/peeling shelf coating;* Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board and bubbling paint;* Chipped laminate was noted on counter edges of the center island, the back splash was pulling away from the wall along the back counter, the counter near the back corner was pulling apart at the seam; * An open box of paper tray liners was stored on the floor next to the stove, multiple pieces of food and other debris were noted on the clean papers and inside the box;* The ice machine had spills and debris on the lower vent slats, broken and missing slats were noted as well;* Cobwebs, dust and dead insects were noted in the windowsill, the screen to the open window had a thick layer of dust and debris on it and multiple chips with exposed particle board noted; and* The ceiling vent near the kitchen entrance had thick accumulation of dark gray dust.The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED), Staff 3 (Maintenance Director) and Staff 4 (Dietary Services Manager) on 09/09/24. The staff acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the main kitchen on 02/05/25 showed the following areas needed cleaning or repair:* Missing covers were noted on the lights in the dry storage;* Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment, and at the door edges;* Shelving in the Victory refrigerator had rust and chipped/peeling shelf coating;* Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board and bubbling paint;* The ice machine had broken and missing slats to the bottom vents;* The interior walls under the sink by the range had black stains along the interior walls; and* Doors and door frames throughout the kitchen had scuffs, scrapes, and/or gouges with bare wood exposed, rendering the surfaces uncleanable.The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 3 (Maintenance Director), Staff 4 (Dietary Services Manager), and Staff 5 (Business Office Manager) on 02/05/25. The staff acknowledged the findings.

Based on observation and interview, 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 C240.

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

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C240.
Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C240.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 240.

Based on interview and record review, conducted during a site visit on 04/22/24 the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 4) was substantiated. Findings include, but are not limited to:Interviews with Staff 1 (Administrator) and Staff 2 (RCC) were conducted:" Staff 1 stated the incident occurred and a facility self-report was made." Staff 2 stated s/he administered the incorrect medication dose and completed the associated incident report.Review of Resident 4's MAR, dated 11/01/23 through 11/30/23, and signed prescriber order, dated 12/09/23 indicated s/he was ordered "clonazepam 1 MG TAB - 0.5 tablet (0.5mg) by mouth every day at noon".Review of the incident report, dated 11/05/23, indicated during the 12p, med pass on 11/01/23 and 11/02/23 Staff 2 administered 1mg of clonazepam instead of .5 mg of clonazepam. It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Findings were reviewed and acknowledged by Staff 1.VPC:Staff 1 and 2 will hold MT meetings to review proper MAR reading and procedures and reinforce the importance of matching medications accurately to the MAR.

Based on interview and record review conducted during a site visit on 04/22/2024, it was determined that the facility failed to fully implement an Acuity Based Staffing Tool (ABST) for 1 of 3 sampled residents (#1, # 2 and #3). Findings include, but are not limited to:Interview with Staff 1 (Administrator) was conducted indicating: · The facility reported use of the State Acuity-Based Staffing Tool (ABST) to generate its staffing plan.· Current census: 36 residents· Reported staffing levels:o Day shift: 4 caregivers (CG) / 1 medication technician (MT)o Swing shift: 4 (CG) / 1 (MT)o Night (Noc) shift: 2 (CG) / 1(MT)The following records were reviewed and indicated:· Staff Roster· Resident Rostero Assisted Living: 23 residentso Memory Care: 13 residents· Facility Posted Staffingo Day Shift: 2 CG and 1 MT (MT covers both ALF and MC)o Swing Shift: 2 CG and 1 MT (MT covers both ALF and MC)o Night (Noc) Shift: 1 CG and 1 MT (MT covers both ALF and MC)o Posted staffing does not align with the facility ' s reported schedule.· Facility ABST Toolo Assisted Living: 24 Residentso Memory Care: 13 Residentso Facility ABST does not match Resident Roster. (Staff 1 noted one resident had been removed, as they no longer reside at the facility.)o Facility ABST tool does not reflect current ADL needs for Residents 1, 2 and 3. o Facility is not staffing to the levels indicated by the ABST tool. (Swing shift is short by one caregiver.) It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool.Findings were reviewed with and acknowledged by Staff 1.Verbal Plan of Correction:Staff 1 will audit the ABST tool to ensure that all residents are accurately entered, acuity levels are properly updated, and an accurate staffing plan is generated based on resident needs.

The findings of the re-licensure survey, conducted 11/27/23 through 12/01/23, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the revisit to the re-licensure survey of 12/01/23, conducted 05/13/24 through 05/15/24, 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, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation contained all required elements and addressed sufficient information to develop an initial service plan to meet the resident's needs for 1 of 1 sampled resident (# 2) who was recently admitted to the facility, and the most recent quarterly evaluation was reflective of the resident's current needs for 1 of 2 sampled residents (# 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder.Review of the move-in evaluation identified the following required elements were not documented as being addressed:* Customary routines related to sleeping and bathing;* Interests, hobbies, social, leisure activities;* Spiritual, cultural preferences and traditions;* Personality: including how the person copes with change or challenging situations;* Pharmaceutical and non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * Nutritional habits, fluid preferences and weight if indicated; * Complex medication regimen;* History of dehydration or unexplained weigh loss or gain;* Elopement risk or history;* Recent losses; and* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature.2. Resident 3 was admitted to the facility in 12/2021 with diagnoses including anemia, polyneuropathy, paroxysmal atrial fibrillation, combined systolic (congestive) and diastolic (congestive) heart failure, and edema.Review of the quarterly evaluation revealed the quarterly evaluation was not reflective of the resident's current needs in the following areas: * History of dehydration or unexplained weight loss or gain;* Recent losses; and* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature.The need to ensure the initial move-in contained all required elements and the quarterly evaluations were reflective or the resident's current needs was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

2. Resident 1 was admitted to the MCC in 08/2022, with diagnoses including Parkinson's Disease, anxiety, and dementia.Resident 1's service plan, dated 11/26/23, was not reflective of the resident's current status or did not provide clear instructions to staff in the following areas:* use of wheel chair;* activity participation/involvement; and* challenging behaviors.Observations on 11/28/23, noted Resident 1 sitting in a wheel chair for both meals and activities.In an interview on 11/28/23, Staff 10 (Caregiver) stated Resident 1 used a wheel chair "when needed, depending on how [he/she] is doing that day".On 11/30/23 the need to ensure service plans were reflective of residents current needs and provided clear directions to staff was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager). They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 2 of 4 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder.Interviews with the resident and staff, and review of the current service plan revealed Resident 2's service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas:* Dental status and use of assistive devices;* Dietary and nutrition management including current allergies;* Instructions on non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * Instructions for whom skin impairments should be reported to;* Instructions for whom weight gain or loss, and changes in appetite should be reported to;* Instructions on signs and symptoms of depression to report while on anti-depressant therapy; and* Instructions on signs and symptoms of infection to report while monitoring incision site with sutures.The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to determine and document what action or intervention was needed for the resident with a short-term change of condition, communicate actions or interventions to staff on each shift, and/or to document weekly progress until the condition resolved for 2 of 4 sampled residents (#s 2 and 3) reviewed with changes of condition. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder.Clinical records, including the current service plan, observation notes from 08/27/23 through 11/27/23 were reviewed, and interviews with facility staff and the resident were conducted.The following short-term change of conditions lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and documented weekly progress until the condition resolved:* 09/23/23: Redness in right eye;* 10/20/23: Witnessed fall with no injury reported;* 10/29/23: "Resident has had diarrhea stool for the past 36 hours ....";* 10/31/23: Dark urine;* 11/01/23: Emergency Room visit related to surgical removal of neurofibroma;* 11/02/23: Discontinued medications: Naproxen 500mg (for pain), Atenolol 50mg (for blood pressure), and Benazepril 10mg (for blood pressure);* 11/02/23: New medication order: Senna 8.6mg (for bowel care);* 11/03/23: New medication order: Clindamycin 300mg (antibiotic);* 11/15/23: Abdominal pain and diarrhea;* 11/16/23: Abdominal pain and diarrhea;* 11/19/23: Diarrhea;* 11/23/23: Rash under right breast and on the back;* 11/24/23: Emergency Room visit related to nausea/vomiting and skin infection; and* 11/26/23: Emergency Room visit related to back skin cellulitis, skin maceration and bleeding from neurofibroma.2. Resident 3 was admitted to the facility in 12/2021 with diagnoses including anemia, polyneuropathy, paroxysmal atrial fibrillation, combined systolic (congestive) and diastolic (congestive) heart failure, and edema.Clinical records, including the current service plan, observation notes from 08/27/23 through 11/27/23 were reviewed, and interviews with facility staff and the resident were conducted.The following short-term change of conditions lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and documented weekly progress until the condition resolved:* 09/04/23: " ...leg's toes were weeping a yellow color resident stated that s/he saw blood in the shower ...";* 09/07/23: Shortness of breath;* 09/08/23: Shortness of breath;* 09/10/23: " ...right leg is very infected ...";* 09/23/23: "Wounds on the bottom of residents L foot are very tender and beginning to swell ...";* 11/09/23: Discontinued medications: Aquaphor ointment (for skin care), Ferrous Sulfate 325mg (supplement), and Probiotic (for digestive health);* 11/09/23: "It appears resident is struggling with bouts of depression ...." and* 11/24/23: Unwitnessed fall with no injuries reported.The need to ensure the facility evaluated the resident's short-term changes of condition and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 2 and 4) whose orders were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 2022 with diagnoses including mild cognitive impairment and muscle weakness.Resident 4's current physician orders, dated 11/06/23, and MARs from 11/06/23 through 11/27/23 were reviewed and included the following:* MD order dated 11/07/23 was in place for daily weights to monitor for swelling after a brain injury. Weights were not taken on 11/08/23, 11/11/23, 11/18/23, 11/23/23, and 11/25/23; and* The following medications were not administered on the following dates:- 11/08/23 and 11/10/23 - docusate sodium 250 mg (stool softener);- 11/08/23 Lamotrigine 20 mg (antacid), multi vitamin, Vitamin C and Vitamin D (supplements); and- 11/10/23 bumetanide 1 mg (diuretic).The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Coordinator), and Staff 16 (LPN) on 11/30/23. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder.Review of Resident 2's current physician orders and MARs from 11/01/23 through 11/27/23 revealed the following:* Atenolol 50mg (for blood pressure) two tabs orally twice daily was discontinued on 11/02/23 per legally recognized practitioner order. However, according to the MAR, the medication was administered on 11/03/23 and morning pass 11/04/23;* Atenolol 50mg was ordered to be administered one tab orally daily on 11/02/23 per legally recognized practitioner order. According to the MAR, the medication administration started on 11/07/23;* Senna 8.6mg (for bowel care) was ordered to be administered one tablet orally daily and held for loose stool. According to Observation notes, Resident 2 had diarrhea 11/15/23 and 11/16/23, and Senna 8.6mg was administered on 11/15;* Loperamide 2mg (for diarrhea) was ordered to be administered one tab orally after each subsequent loose stools and if loose stools accompanied by abdominal pain, fever, or blood in stools, alert RN and PCP immediately. According to Observation note on 11/16/23, Resident 2 "stated she still has stomach pain and diarrhea." There was no documented evidence RN and PCP were notified immediately as ordered; and* Resident 2 had two contradicting medications orders: Senna 8.6mg (for bowel care) and Loperamide 2mg (for diarrhea as needed). According to the MAR, both medications were administered on 11/11/23, 11/15/23, and 11/27/23.The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

3. Resident 4 was admitted to the facility in 2022 with diagnoses including mild cognitive impairment and muscle weakness.Resident 4's current physician orders, dated 11/06/23, and MARs from 11/06/23 through 11/27/23 revealed on 11/08/23 Resident 4 refused docusate sodium (stool softener).There was no documented evidence the facility notified the physician or other legally recognized practitioner each time the resident refused to consent to the orders. The need to ensure the facility notified the physician or other legally recognized practitioner of medication and treatment refusals was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to notify the physician/practitioner if a resident refused consent to an order for 3 of 3 sampled residents (#s 1, 2 and 4) who had documented refusals. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 08/2022, with diagnoses including Parkinson's Disease, anxiety, and dementia.Review of Resident 1's MAR, dated 11/01/23 through 11/27/23, revealed the resident refused prescribed doses of medication on five occasions. These included three doses of Sinemet (for Parkinson's symptoms) and two doses of Seroquel (mood stabilizer).There was no documented evidence the facility notified the physician/practitioner when the resident refused consent to the orders.In an interview on 11/29/23, Staff 3 (Resident Care Coordinator) presented the surveyor with a written policy for informing physicians about refusals, and a fax form used to do so. However, Staff 3 stated there was no evidence of notification for any of the refusals for Resident 1.On 11/30/23 the need to ensure residents' physicians were notified of all refusals, unless otherwise directed, was discussed with Staff 1 (Administrator) and Staff 3. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder.Resident 2's MARs from 11/01/23 through 11/27/23 and corresponding Observation notes were reviewed. The resident's records showed the Silvadene 1% cream (for skin care) was refused on 12 occasions.There was no documented evidence the facility notified the physician or other legally recognized practitioner each time the resident refused to consent to the orders. The need to ensure the facility notified the physician or other legally recognized practitioner of medication and treatment refusals was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly hired staff (#s 7, 8, and 9) completed pre-service and 30 day competency training as required. Findings include, but are not limited to:Training records for Staff 7 (CG), hired 7/20/2023, Staff 8 (CG), hired 06/15/23, and Staff 9 (MT), hired 03/20/23, were reviewed with Staff 4 (Business Office Manager) on 11/29/23.There was no documented evidence Staff 7, 8, and 9 had completed the following required Memory Care Community pre-service training:* Pre-service Infectious Disease Prevention for community based care;* Environmental factors for a resident's well being;* Family support and role of the family;* Behaviors that require evaluation and assessment;* Use of supportive devices with restraining qualities, and* Changes associated with normal aging.The need to ensure staff completed all required pre-service training before working independently was discussed with Staff 1 (Administrator) on 11/30/23. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C252, C260, C270, C303, and C305.

Based on interview and record review, it was determined the facility failed to fully evaluate each resident for activities and develop an individualized activity plan based on their activity evaluation, for 1 of 1 sampled resident (#1) whose records were reviewed.Resident 1 was admitted to the MCC in 08/2022, with diagnoses including Parkinson's Disease, anxiety, and dementia.Resident 1's service plan, dated 11/26/23, included information about past and current hobbies and interests. However, the facility had not fully evaluated the resident regarding:* Current abilities and skills;* Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities, based on information gathered from the evaluation.On 11/30/23, the need to ensure the facility completed a thorough activity evaluation, developed an individualized activity plan, and provided meaningful daily activities for each resident was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Coordinator). They acknowledged the findings.

The findings of the desk review, conducted on 10/23/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

The findings of the on-site investigation, conducted 05/22/22 through 05/22/22, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the on-site investigation, conducted 05/22/23 through 05/22/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the on-site investigation, conducted 05/22/23 through 05/22/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the kitchen inspection, conducted on 04/04/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first re-visit to the kitchen inspection of 04/04/23, conducted 08/28/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to maintain the kitchen clean and in good repair and follow food safety guidelines in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:During the tour of the kitchen on 04/04/23, the following was observed: 1. The temperature gauge on the outside of the triple refrigerator closest to the kitchen entrance read 46 degrees Fahrenheit. The temperature gauge on the inside of the refrigerator read 30 degrees Fahrenheit. Staff 1 (Administrator) was apprised of the malfunctioning refrigerator. Staff 2 (Dietary Director) obtained temperatures of containers of milk and mayonnaise using a probe thermometer which measured 48 degrees Fahrenheit and 47 degrees Fahrenheit respectively. During an interview with Staff 2, he indicated he did not know how long the refrigerator temperatures had exceeded the maximum allowed temperature to ensure food safety. The facility was instructed to dispose of all protein-based food. Staff 1 stated the maintenance director would evaluate the malfunctioning refrigerator and repair it or refer to the manufacturer to fix the issue prior to resuming food storage.2. The following areas were noted to be in need of cleaning and repair: * There was build-up of brown/black matter and food particles on multiple food carts; * The handles on the triple refrigerator by the entrance were broken and covered with duct tape;* The garbage cans were uncovered; and* The coating on an attachment for the stand mixer had an area where the rubber coating had torn and metal was exposed.3. The following unsafe food handling and infection control practice were observed:* Plates of pie were transported to the memory care uncovered;* Servers were not wearing aprons;* Staff 3 (Facility Service Aide) was observed to wash her hands with gloves on and then to dry out a clean coffee pot with a paper towel; and* Staff 2 was observed to touch a clipboard and a pen with gloves on and then plate ready to eat foods. The need to ensure the kitchen was maintained clean and in good repair and follow food safety guidelines in accordance with the Food Sanitation Rules discussed with Staff 1 on 04/04/23. She acknowledged the findings.

Based on observation, record review and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.