Avamere at Park Place

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 clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen and the dining room on 12/31/25, from 10:45 am through 12:15 pm, revealed the following deficient practices: 1. Main Kitchen a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, pink slime (biofilm), and/or grease was visible on or underneath the following: * Pipes, walls, and flooring behind/underneath the commercial ware washing machine; * Top of dish machine; * Metal movable “speed” racks; * Light fixture housing in walk-in cooler; * Electrical conduit/piping to light fixture and above the door in the walk-in cooler; * Walk-in cooler condenser fan covers; * Juice machine (where spouts connect to machine) with splash accumulation; * Industrial can opener and housing; * Top of standing convection oven in rear prep area; * Heavy accumulation of ice on interior right wall of walk-in cooler; * Fire suppression sprinkler heads throughout the kitchen; * Interior of commercial ice machine; and * Ceiling vent covers throughout the kitchen. b. Items to be repaired/replaced: * All green racks (Metro racks) in the walk-in cooler observed to have significant areas of rust, rendering them incapable of being properly cleaned or sanitized; * Water observed leaking from a pipe under the commercial ware washing machine; * Ware washing machine was missing the cover for one of the temperature gauges; * Leak running down the right side wall of walk-in cooler, resulting in an accumulation of ice; * Fluorescent overhead lights in dry storage area; * All lights in overhead exhaust system (vent-a-hood); and * Open cabinet in dining room holding ware washing machine racks has missing laminate resulting in exposed particle board that is not able to be adequately cleaned and/or sanitized. c. Multiple food items in walk-in cooler without an open date. d. Multiple damaged canned goods in dry storage area intermingled with useable canned goods. e. Multiple damaged canned goods on storage rack adjacent to the front cooking line intermingled with useable canned goods. f. No clear system in place to prevent the intermingling of damaged canned goods with useable canned goods. g. Food item in walk-in cooler with a manufacturer’s expiration date of 11/22/25. h. Multiple uncovered food items plated for service observed in the walk-in, potentially resulting in cross contamination of the food items. i. Kitchen staff member washing and handling clean dishes was observed to not have facial hair effectively restrained. j. Oven racks being stored directly on the floor behind the convection oven. k. No testing strips available for staff to validate if the parts per million concentrations of the surface sanitation solution buckets were within the effective range for sanitizing food service/prep surfaces. At approximately 12:15 pm, the surveyor reviewed the findings with Staff 1 (Executive Director) and Staff 2 (Dining Services Manager). The deficiencies were acknowledged by Staff 1 and Staff 2.

A) 1. All noted areas with an accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, pink slime (biofilm) and/or grease have been cleaned thoroughly and appropriately. 2. A daily, weekly, monthly, and quarterly cleaning task list has been implemented for the dining team members to carry out to ensure cleanliness. 3. The Executive Director and Dining Services Director will conduct a walkthrough weekly as well as monthly as part of the community's CQI program to ensure complance in cleanliness of the kitchen and service areas. 4. The Executive Director is responsible to see that corrections are completed and monitored. B) 1. Items needing repair or replaced have been ordered and/or scheduled for repair. 2 The Executive Director and Dining Services Director will conduct an audit of the kitchen to include an environmental walkthrough to ensure that any items needing repair or replaced is documented with an action plan on a regularly scheduled basis. 3. This system will be evaluated once weekly and monthly as part of the CQI process. 4. The Executive Director is responsible to see that the corrections are completed and monitored. C) 1. All food items in the walk-in cooler have been audited to ensure that a open date is placed on to all open items. 2. The dining service team has been inserviced on the importance of labeling opened items with the open date for food safety precautions. 3. The Executive Director and Dining Services Director will do an audit walkthrough of the walk-in to ensure all opened items are open dated on a recurring basis. 3. This system will be evaluated once weekly and monthly as part of the CQI process. 4. The Executive Director is responsible to see that the corrections are completed and monitored. D) 1. The damaged canned goods in the dry storage area were removed and disposed of. 2. The dining services team has been inserviced on not having damaged canned goods intermingled with useable canned goods. 3. The Executive Director and Dining Services Director will evaluate this area on a monthly basis as part of the CQI process. 4. The Executive Director is responsible to see that corrections are completed and monitored. E) 1. The damaged canned goods on the storage rack adjacent to the front cooking line were removed and disposed of. 2. The dining services team has been inserviced on not having damaged canned goods intermingled with useable canned goods on the storage rack. 3. The Executive Director and Dining Services Director will evaluate this area on a monthly basis as part of the CQI process. 4. The Executive Director is responsible to see that corrections are completed and monitored. F) 1. A system has been put into place to prevent the intermingling of damaged canned goods with useable canned goods that has three layers of preventative measures. 2. Dining staff have been inserviced that the cook on shift receiving the food order is to check all canned goods upon delivery and return any damaged canned goods with the deliverer. The dining services director will then also audit inventory to ensure no damaged canned goods once the shipment has been completed. The Executive Director and Dining Services Director will conduct weekly walk throughs of the various storage areas to ensure the removal of any damaged canned goods not previously identified. 3. This system will be evaluated monthly as part of the CQI process. 4. The Executive Director is responsible to see that the corrections are completed and monitored. G) 1. The expired food item identified was immediately removed from the walk-in cooler. 2. Dining staff have been inserviced the importance of checking expiration dates when using and storing food products for food safety measures. 3. The Executive Director and Dining Services Director will conduct a weekly walkthrough to ensure no expired product is in the walk-in cooler. This system will also be reviewed monthly as part of the CQI process. 4. The Executive Director is responsible to see that the corrections are completed and monitored. H) 1. The uncovered food items were immediately removed from the walk-in and replaced with a covered option. 2. Dining staff have been inserviced on cross contamination of food products and the importance of ensuring food is not left uncovered in the walk-in. 3. The Executive Director and Dining Services Director will conduct a walkthrough weekly to ensure that all items in the cooler are always covered. 4. The Executive Director is responsible to see that the corrections are completed and monitored. I) 1. The kitchen staff member was instructed and provided the necessary equipment needed to have their facial hair effectively restrained. 2. Dining staff have been inserviced on proper sanitation procedures including the restraining of any visible hair. 3. The Dining Services Director will ensure that dining staff upon hire and recurring there after on a regularly scheduled basis are re-trained on the restraining of visible hair. 4. The Executive Director is responsible to see that the corrections are completed and monitored. J) 1. The oven racks identified behind the convection oven were removed and placed into a proper storage area. 2. The dining team have been inserviced on storing the oven racks in the designated area. 3. The Executive Director and Dining Services Director will conduct a weekly walkthough to ensure the oven racks are in their designated storage area. 4. The Executive Director is responsible to see that the corrections are completed and monitored. K) 1. Testing strips were immediately ordered and are currently on hand for staff to validate if the parts per million concentrations of the surface sanitation solution buckets are within the effective range for sanitizing food service/prep surfaces. 2. Dining staff were trained on proper test strip logging, procedure, and verification of effective ranges. 3. This Executive Director and Dining Services Director will conduct a weekly walkthrough to ensure sanitization buckets are being properly tested. This system will also be reviewed monthly as part of the CQI process. 4. The Executive Director is responsible to see that the corrections are completed and monitored.

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

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

Based on interview and record review, it was determined the facility failed to ensure resident injuries were promptly investigated to rule out abuse and/or neglect and reported to the local Department office if abuse could not reasonably be ruled out for 1 of 1 sampled residents (#1) who experienced injuries of unknown cause. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2024 with diagnoses including mild cognitive impairment, amnesia, and anxiety disorder. Resident 1 used a wheelchair for mobility and the medical record noted “For this resident emergency medical services (EMS) is called to assist when s/he falls to ensure safety.” Review of the record showed an incident report dated 02/04/26 which noted “Resident 1 reported s/he scraped his/her leg on the side of bed and fell to his/her knees. When asked, the resident reported they could not remember who helped them up but s/he must have had help because s/he is not sure they got up alone. Resident showing signs of confusion and unable to recall events in detail. Not witnessed.” A progress noted dated 02/05/26 titled “Fall” documented “resident is reporting that s/he is having a hard time bearing weight on right leg. Pain level 8 in right knee, lower outside of knee.” The investigation did not reasonably rule out abuse or neglect because the resident experienced an injury and was unable to say if they were alone or how the injury happened. The investigation dated 02/04/26 was not reviewed by the Administrator or reported to the local Department. 2. The LPN skin assessment dated 03/4/26 noted: “Groin area not assessed but per verbal update from Home Health Nurse on 03/4/26, there is what appears to be a skin tear on labia.” There was no documented explanation of the injury or how it happened. The next LPN skin assessment, dated 03/15/26, noted “groin area not assessed but per verbal update from Home Health Nurse, there is still redness and what appears to be a skin tear on labia.” The discovery of the unexplained wound was an injury of unknown cause. There was no documented evidence the wound was investigated to determine the cause, rule out abuse or neglect, and was not reported to the local Department office. 3. An ISP dated 03/15/26 documented the discovery of a “circular open area below right knee” and instructed staff to “monitor for signs of infection, drainage, hot to touch, odor or pain.” The unexplained wound constituted an injury of unknown cause. There was no documented evidence of an investigation or report to the Department office. The injuries were reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 15 (Assistant Regional Director of Operations), Staff 16 (Regional Executive Director), and Staff 3 (LPN) on 04/29/26 at 3:00 pm. Staff 15 initiated reporting of the 3 incidents to the local department office and confirmation of the report was received on 04/29/26. The need to ensure unexplained injuries were investigated and immediately reported to the local department office, if abuse or neglect could not be ruled out, was discussed with Staff 1, Staff 2, Staff 3, Staff 15, and Staff 16 at 3:30 pm. They acknowledged the findings.

1. Resident 1 injuries of unknown origin were reported to Adult Protective Services. 2. The Executive Director (ED), Licensed Nurses (LN), and Resident Care Coordinators (RCCs) have reviewed Oregon Assisted Living and Residential Care Abuse Reporting and Investigation Guide for Providers to ensure understanding of the community’s requirement for investigating injuries of unknown origin as well as other incidents to determine if abuse and neglect can be ruled out, and when indicated reporting immediately to the appropriate state agencies.Training on reporting requirements will be completed for all staff upon hire and annually thereafter as a refresher. 3. This system will be evaluated 5 days a week as part of daily standup process. During standup, Incident reports will be reviewed and when indicated, incidents will be immediately reported to APS. Additionally at standup, the 24-hour report will be reviewed, which includes a review of all progress notes written in the past 24 hours to identify any documented incidents or injuries that may not have had an incident report completed. On Mondays, the 72-hour report will be reviewed to include documentation from the weekend. 4. The Executive Director will be responsible for maintaining this system.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

Based on observation, 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 (#1 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 08/2022 with diagnoses including esophagitis and consequently was diagnosed with Barrett esophagus (damaged esophagus) in 06/2023. Review of Resident 4's physician orders and MARs from 03/01/26 through 04/27/26 revealed the following: a. Discharge orders dated 03/03/26 instructed providing a diet texture “soft and bite sized. Please provide naturally-pureed solids (e.g. mashed potatoes, apple sauce, yogurt, pudding) with each meal for comfort.” During observations on 04/29/26 and 04/30/26, Resident 4 was noted to be served regular textured food ordered from the standard menu, and naturally pureed solids were not offered. During interviews with Staff 11 (Cook) on 04/28/26 at 3:44 pm and Staff 17 (Culinary Director) on 04/30/26 at 9:10 am, both confirmed Resident 4 was not listed on the facility’s Resident Dietary Communication form, and no special diet instructions were implemented. Staff 2 (RN) notified the kitchen’s Person In Charge during sharing of findings and confirmed the prescribed diet was put in place. No negative outcome for Resident 4 was reported or observed, and facility update the diet texture information. b. Physician orders, dated 03/03/26, included the following: “Metoprolol succinate (for blood pressure) take 0.5 tablets by mouth every morning; hold if SBP [systolic blood pressure] < 100 or heart rate < 60; Please recheck BP [blood pressure] and heart rate at noon (during second med pass).” There was no documented evidence resident’s blood pressure and heart rate were checked at noon starting on 03/03/26. c. Physician orders, dated 04/25/26, stated, “please discontinue all previous meds and give [the new list].” The new list did not contain the previously given orders to administer empagliflozin 10mg (for heart failure), lisinopril 5mg (for high blood pressure), spironolactone 25mg (for heart failure), and torsemide 20mg (for edema). According to the MARs, staff continued to administer those medications on 04/26/26 and 04/27/26. d. Physician orders, dated 03/03/26, provided specific instructions for aspiration precautions including instructions to staff in case the resident “begins to cough, choke, sneeze, have wet voice or runny nose/eyes while eating...” Staff 12 (CG) was observed leaving a lunch tray in Resident 4’s room on 04/29/26 at 12:06 pm and locking the door upon exiting. During the interview on 04/30/26 at 11:05 am, Staff 12 confirmed caregivers “usually leave trays with resident and leave, then kitchen server comes to pick it up.” There was no evidence facility staff was monitoring Resident 4 when s/he dined in the room. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3 (LPN), Staff 15 (Assistant Regional Director of Operations), and Staff 16 (Regional Executive Director) on 04/30/26 at 3:42 pm. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

Based on observation, 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 (#1 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 08/2022 with diagnoses including esophagitis and consequently was diagnosed with Barrett esophagus (damaged esophagus) in 06/2023. Review of Resident 4's physician orders and MARs from 03/01/26 through 04/27/26 revealed the following: a. Discharge orders dated 03/03/26 instructed providing a diet texture “soft and bite sized. Please provide naturally-pureed solids (e.g. mashed potatoes, apple sauce, yogurt, pudding) with each meal for comfort.” During observations on 04/29/26 and 04/30/26, Resident 4 was noted to be served regular textured food ordered from the standard menu, and naturally pureed solids were not offered. During interviews with Staff 11 (Cook) on 04/28/26 at 3:44 pm and Staff 17 (Culinary Director) on 04/30/26 at 9:10 am, both confirmed Resident 4 was not listed on the facility’s Resident Dietary Communication form, and no special diet instructions were implemented. Staff 2 (RN) notified the kitchen’s Person In Charge during sharing of findings and confirmed the prescribed diet was put in place. No negative outcome for Resident 4 was reported or observed, and facility update the diet texture information. b. Physician orders, dated 03/03/26, included the following: “Metoprolol succinate (for blood pressure) take 0.5 tablets by mouth every morning; hold if SBP [systolic blood pressure] < 100 or heart rate < 60; Please recheck BP [blood pressure] and heart rate at noon (during second med pass).” There was no documented evidence resident’s blood pressure and heart rate were checked at noon starting on 03/03/26. c. Physician orders, dated 04/25/26, stated, “please discontinue all previous meds and give [the new list].” The new list did not contain the previously given orders to administer empagliflozin 10mg (for heart failure), lisinopril 5mg (for high blood pressure), spironolactone 25mg (for heart failure), and torsemide 20mg (for edema). According to the MARs, staff continued to administer those medications on 04/26/26 and 04/27/26. d. Physician orders, dated 03/03/26, provided specific instructions for aspiration precautions including instructions to staff in case the resident “begins to cough, choke, sneeze, have wet voice or runny nose/eyes while eating...” Staff 12 (CG) was observed leaving a lunch tray in Resident 4’s room on 04/29/26 at 12:06 pm and locking the door upon exiting. During the interview on 04/30/26 at 11:05 am, Staff 12 confirmed caregivers “usually leave trays with resident and leave, then kitchen server comes to pick it up.” There was no evidence facility staff was monitoring Resident 4 when s/he dined in the room. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3 (LPN), Staff 15 (Assistant Regional Director of Operations), and Staff 16 (Regional Executive Director) on 04/30/26 at 3:42 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 09/2024 with diagnosis including mild cognitive impairment. The resident's 04/01/26 to 04/30/26 MARs and physician orders were reviewed, and the following was identified: a. There were blanks on the MAR for the following medications: * Fluticasone 50 MCG/ACT (for congestion); * Lidocaine ointment 5% (for pain); * Nystatin powder 100,000 unit/gram (for fungal rash); and * Diclofenac sodium topical (for pain). In interview on 04/30/26 at 11 am, Staff 3 (LPN) confirmed the medications were not given on 04/05/26 due to a staff error. b. There were no signed, written orders in the resident’s record for the following treatments on the MAR: * Dermoplast spray (for pain); and * Nystatin powder 100,000 unit/gram (for fungal infection). The need to ensure orders were carried out as prescribed and written signed physician or other legally recognized practitioner orders were documented in the resident's record was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 15 (Assistant Regional Director of Operations), Staff 16 (Regional Executive Director), and Staff 3 (LPN) on 04/30/26 at 3:00 pm. They acknowledged the findings.

Resident #4 • Upon identification, the RN immediately verified and implemented the physician ordered soft and bite sized diet with naturally pureed solids at each meal. The resident was added to the facility’s Resident Dietary Communication form, and dietary staff were notified. • Blood pressure and heart rate monitoring for metoprolol administration was immediately initiated and documented per physician order. • Medications discontinued by the provider on 04/25/26 (empagliflozin, lisinopril, spironolactone, torsemide) were immediately stopped once identified, and MARs were corrected. • Aspiration precautions were reviewed, and staff were re instructed that Resident #4 requires monitoring during meals when eating in their room. Tray delivery without supervision was discontinued. Resident #1 • LN reviewed the MAR and identified missed medication doses and documentation errors. MARs were corrected to reflect accurate documentation. • Medication and treatment orders have been reconciled to ensure there is a signed physician order for all medications and treatments being administered. 2. A training has been scheduled with the entire clinical team to review the triple check process for all new orders as well as the requirement to have signed physician orders and the filing process. Training will also include the need for ISPs to be printed for all order changes and if the order change is related to diet orders, a copy must be given to the kitchen to update their records as well. Weekly MAR audits will be completed by the RCC to identify any missing documentation as well as to ensure parameters are being followed. Additional training will be provided to Med Aides when concerns are identified. 3. This system will be reviewed weekly through MAR audits and parameter audits as well as monthly as part of the CQI process which includes a review of all weekly audits as well as a reconciliation of diet orders. Physician orders will also be reconciled quarterly for all residents to ensure all medications and treatments have a signed order. 4. The Executive Director will be responsible for maintaining this system.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

Based on interview and record review, it was determined the facility failed to notify the prescriber when a resident refused to consent to orders for 1 of 4 sampled residents (#2) who had documented medication and/or treatment refusals. Findings include, but are not limited to: 1. Resident 2 moved into the community in 11/2024 with diagnoses including gastroesophageal reflux disease and a history of right humerus and left femur fractures. Resident 2’s MARS dated 04/01/26-04/28/26 and physician’s orders dated 03/12/26 were reviewed and revealed Resident 2 refused to consent to the following orders: Bupropion, clopidogrel, omeprazole, polyethylene glycol, trazodone, rosuvastatin: one occasion; Buspirone, oxycodone: two occasions; Calcium carbonate-cholecalciferol: three occasions; Liquid protein supplement: 17 occasions; and Morphine sulfate: four occasions. During an interview on 04/30/26 at 1:05 pm with Staff 3 (LPN), she stated the prescriber was to be faxed and a progress note made each time a resident refused his/her medication. There was no documented evidence the facility consistently notified the prescriber each time the resident refused to consent to the prescriber’s orders. The need to ensure the prescriber was notified of the resident’s refusal to consent to orders was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3, Staff 15 (Assistant Regional Director of Operations) and Staff 16 (Regional ED) on 04/30/26 at approximately 4:15 pm. They acknowledged the findings.

1. Physician for resident #2 was faxed a copy of all refusals for past 30 days. 2. To prevent recurrance, all Medication Aides will be re-educated on the regulatory requirement to notify providers with all medication or treatment refusals, unless we have an order in place stating the provider does not want to be notified. A list has been printed of providers who do or do not want to be notified has been printed and placed in the med room for quick reference. This list will be updated at least monthly. The 24-hour report will be reviewed at standup to identify any refusals and verify necessary notifications were completed. RCC will do a weekly audit of refusals to verify compliance. 3. This system will be evaluated weekly with refusal audits as well as monthly as part of our Continuous Quality Improvement (CQI) process which includes a review of the weekly audit results. 4. The Executive Director will be responsible for maintaining this system.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on interview and record review, it was determined the facility failed to maintain an accurate MAR, provide instructions and resident specific parameters for PRN medications for 2 of 4 sampled residents (#s1 and 2) whose MARS were reviewed. Findings include, but are not limited to: Resident 2 moved into the community in 11/2024 with diagnoses including gastroesophageal reflux disease and a history of right humerus and left femur fractures. Resident 2’s MARS dated 04/01/26-04/28/26 were reviewed. Resident 2 had three PRN medications for pain and lacked instructions to guide unlicensed staff as to which medication to administer for the resident’s complaints of pain: *Acetaminophen 325mg, give two tablets by mouth every six hours as needed for pain or fever greater than 100F; *Morphine sulfate 100mg/5ml, give 0.5ml by mouth every hour as needed for pain or SOB (shortness of breath); and *Oxycodone HCl 5mg, give 0.5 tablet by mouth as needed two times daily as needed for pain. Oxycodone HCl was administered one time between 04/01/26-04/28/26. Resident 2 had two PRN medications for nausea and lacked instructions to guide unlicensed staff as to which medication to administer for the resident’s complaints of nausea: *Ondansetron 4mg, give one tablet by mouth every four hours as needed for nausea; and *Haloperidol lactate 2mg/ml, give 0.25ml by mouth every two hours as needed for anxiety, agitation, hallucinations, nausea, vomiting. Ondansetron was administered five times and Haloperidol was administered one time between 04/01/26-04/28/26. Resident 2 had a PRN order for Flonase (a nasal spray that treats allergy symptoms) that lacked specific instructions for staff as to when the medication should be administered. During an interview on 04/29/26 at 10:15 am with Staff 3 (LPN), she acknowledged the lack of specific instructions for the PRN use of Flonase and the sequential order of administration for pain and nausea medications. The need to ensure the MARs included instructions and resident-specific parameters for PRN medications was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3, Staff 15 (Assistant Regional Director of Operations) and Staff 16 (Regional ED) on 04/30/26 at approximately 4:15 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 09/2024 with diagnosis including mild cognitive impairment and chronic pain. The 02/12/26 service plan documented “Resident requires assistance with medication administration”. The resident’s 04/01/2026 through 04/30/26 MARs and physician orders were reviewed. The following was identified: 1. The resident had used two as-needed prescriptions for pain, one for acetaminophen and one for oxycodone. There were no parameters instructing staff when to use the narcotic pain medication. 2. The MAR instructions for Loperamide 2mg (for diarrhea) was incorrectly transcribed from the physician's order dated 04/19/26. The need to ensure there were accurate instructions and parameters in place for multiple PRN medications for the same purpose was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 15 (Assistant Regional Director of Operations), Staff 16 (Regional Executive Director), and Staff 3 (LPN) on 04/29/26 at 3:00 pm. They acknowledged the findings.

1. For Resident #1 and Resident #2, the registered nurse (RN) reviewed all current physician orders and Medication Administration Records (MARs). Orders with multiple PRN medications for the same indication for use were corrected give clear instructions for use. The incorrectly transcribed loperamide order was corrected. 2. A meeting has been scheduled with the clinical to review the triple check process in full to include the following: • Proper transcription orders • Required elements of PRN medication instructions • Clear instructions for the unlicensed med aides when multiple PRN medications exist for the same indication for use. 3. This system will be evaluated quarterly for all residents as part of the order reconciliation which includes LN review of all orders, including PRN directions and parameters. Orders will then be sent to the provider for signature. PRN parameters will also be reviewed monthly as part of our CQI process. 4. The Executive Director will be responsible for maintaining this system.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

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 kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 06/05/25 at 10:45 am, the facility kitchen was observed to need cleaning and repair in the following areas: Areas in need of cleaning: * Walk in refrigerator fans – heavy accumulation of dust; * Ice maker vent – accumulation of dust; * Oven door front and handle – food drips/spills; * Wall behind grill/stove – grease drips; * Exterior of deep fat fryer – grease drips/spills; * Shelf below grill – grease/debris; * Floor between service line and ice maker – significant build up of black matter; * Wall behind dishwasher – build up of black matter; * Commercial can opener blade and housing– blade with build up of food and finish worn off/black matter on housing; * Ceiling vents between service line and cooking equipment – significant build up of dust; and * Exterior of hood over cooking equipment - dusty. Areas in need of repair: * Dry storage ceiling lights – one with out cover and one without working bulbs; * Dishwasher temperature gauges – difficult to read related to being filled with water; and * Ceiling light above prep area – one side not securely attached to ceiling. Other areas of concern included: * Colored cutting boards – heavily scored and finish worn. * Staff not always washing hands between glove changes. * Beard restraints not being used. The areas of concern were observed and discussed with Staff 1 (Dietary Manager) and discussed with Staff 2 (Executive Director) on 06/05/25. The findings were acknowledged.

Walk in refridgerators fans were deep cleaned and serviced on 6/23/25. Contractor explained what we need to do to keep them clean and serviced. They are now added to our weekly cleaning schedule and biannually will be serviced by an outside provider to assure they clean and not leaking. A new daily cleaning schedule was put in place on 6/23/25 to address deficincies with dust on the ice maker, food drips/spills on oven door and handle, wall behind the grill/stove, exterior of deep fat fryer, shelf below grill, floor between service line and ice maker, wall behind dishwasher, ceiling vents between service line and cooking equipment, exterior of hood over cooking equipment. Staff will be responsible daily for deep cleaning a different area of the kitchen. Dietary Manager will track daily cleanings on the sign off sheet. Dietary manger and Executive Director will audit the cleaning schedule documentation and walk through the kitchen for a visual audit every Thursday to assure the schedule is being followed and deep cleaning is being completed. We have ordered a new commercial can opener to address the wear and residue issue identified in the SOD waiting for it to arrive, will replace the old one as soon as it arrives. All cutting boards in kitchen were replaced on 6/23/25. Dishwasher guage was replaced on 6/23/25 Maintenance Director repaired the dry storage ceiling lights and the ceiling lights above the prep area on 6/25/25 Inservice scheduled with all kitchen staff to address issues of beard restraints not being worn and to review hand washing and glove wearing policy and procedure. Going forward we will hold monthly inservice for all dietary staff to review safe food practices.

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 kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Finding include, but are not limited to: On 02/01/24 at 10:50 am, the following practices were observed: * The rolling cart in walk in refrigerator had several pans of uncovered items. Multiple staff were observed in and out of refrigerator, creating potential for cross contamination. Vendor delivery staff also was in refrigerator delivering food products. * The facility failed to have pasteurized eggs. The menu allowed for "eggs any style." The facility's vender had been unable to obtain pasteurized eggs. Until pasteurized eggs were available, the facility ensured eggs would be served fully cooked for residents. * Ceiling vents and light covers between the steam table and stove had build up of dust. * The interior doors of the bottom convection oven had heavy build up of grease. * Staff were not always changing gloves and washing hands between dirty and clean tasks. The findings were discussed with Staff 1 (Dietary Manager) and Staff 2 (Executive Director) on 02/01/24. The findings were acknowledged.

C-240 The rolling cart in walk in refrigerator had several pans of uncovered items. 1.  A cover was ordered on 2-8-24 and received on 2-10-24. (Sealcover Bun Rack Cover). 2.  Staff has been instructed of proper usage. 3.  DSM has confirmed proper fit and will monitor daily.  This item will also be reviewed in monthly CQI Audit. 4.  DSM will monitor proper usage of the rack cover daily, and ED will monitor through the monthly CQI Audit. C-240 Pastuerized eggs not available. 1.Pastuerized eggs have been located with vendor and special ordered. (2-7-24) 2.  Pastuerized eggs will continue to be special ordered from vendor and available to serve residents. 3.  DSM will ensure that pastuerized eggs are available and ED will assist with the ordering when needed.  Monitored through montly CQI Audit. 4.  DSM and ED will monitor and ensure that pastuerized eggs are ordered in a timely matter and always in stock and available. C-240 Dust on vents and light fixtures between the steamtable and stove. 1.  Ceiling vents and light fixtures will be cleaned and any needed repairs made.  Cleaning task lists will be revised to include these vents and fixtures. 2.  Maintenance Director will clean the vent grates and light fixtures. Repairs will be made as needed.  Vent grates and light fixtures will be clean and free of dust. 3.  A TELS task will be added, for monthly cleaning by maintenance department.  Kitchen staff will surface dust the vents per the revised weekly cleaning tasks.   Monthly CQI audits to monitor. 4.  Kitchen staff, DSM, MD will ensure the task is completed.  ED will also oversee and monitor to ensure the task is completed and that the vent grates and light fixtures remain dust free and clean.  Monthly CQI Audits C-240 Grease on inside of Convection oven doors. 1.  A special cleaner will be purchased, as per the manufacturers instructions, to remove the grease and clean the oven doors. 2.  The task will be designated as a weekly task, or as needed, and added to the kitchen cleaning log. 3.  All kitchen staff will be trained to complete the task, following the revised cleaning task log.  CQI  Audits will ensure the cleaning task is being completed. 4.  DSM will ensure that kitchen staff are trained, and that the cleaning log is being completed, and the oven doors are properly cleaned.  ED will monitor, confirming that the trainin takes place and that the task is being completed. C-240 Staff not cleaning hands, washing hands, changing gloves properly. 1. The specific staff member has been given additional instruction and training, with the assistance of an interpreter. 2.  All kitchen staff and dining servers have be reminded at a meeting, of proper hand sanitation when preparing food and serving.   Training for all new hires will continue through Relias training, and in new hire orientation. 3. DSM will monitor all kitchen employees for proper hand sanitation, glove changing and hand washing.  Dining Room manager will additionally monitor and assist in training for both servers and kitchen employees. 4.  ED will monitor both the kitchen and dining room concerning all hand sanitation issues and ensure that training is up to date.

The findings of the kitchen inspection, conducted 02/01/24, 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 02/01/24, conducted 04/10/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors and available for inspection at all times. Findings include, but are not limited to: A tour of the facility conducted on 04/24/23 identified the following required postings were not displayed: * The name of the administrator or designee in charge; and * The current facility staffing plan. On 04/26/23, the need to ensure all required postings were in an accessible and conspicuous location for residents and visitors was discussed with Staff 1 (Regional VP of Operations). She acknowledged the findings.

1. Required postings were corrected at time of survey including current staffing plan. 2 and 3. Postings will be reviewed monthly and updated as needed. These postings are made visable for staff, residents and visitors. 4. ED/RCC/MOD will be responsible to ensure that postings remain current and up to date.

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors and available for inspection at all times. This is a repeat citation. Findings include, but are not limited to: A tour of the facility conducted on 08/23/23 identified the following required posting was not displayed: * The name of the administrator or designee in charge. On 08/24/23, the need to ensure all required postings were in an accessible and conspicuous location for residents and visitors was discussed with Staff 2 (Corporate Traveling RN). He acknowledged the findings.

1. Required postings have been corrected and posted, including current staffing plan. 2. and 3. Postings will be reviewed as needed. These postings are made visable for staff, residents and visitors. 4. ED/RCC/MOD will be responsible to ensure that postings remain current and up to date.

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 were reviewed quarterly for 4 of 6 sampled residents (#s 2, 3, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 01/2021 with diagnoses including diabetes and chronic kidney disease. a. Resident 2's service plan dated 07/27/22 was not updated quarterly. b. During an interview with Staff 3 (RCC) on 04/24/23, Resident 2 was identified to be administered medications by facility staff. The service plan noted the resident self-administered his/her own medications. The need to ensure the service plans were updated at least quarterly and reflected residents' current needs was reviewed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Travel RN) on 04/26/23 at 10:30 am. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 08/2012 with diagnoses including Alzheimer's dementia. Observations and interviews with the resident and staff during the survey on 04/24/23 and 04/25/23, revealed the service plan dated 02/16/23, was not reflective in the following areas: * No longer on hospice; * Was bedbound and no longer transferred out of bed; * No longer had bed canes on his/her bed; * No longer used a walker; * Was using his/her oxygen continuously, not PRN; * Was no longer being administered aspirin; and * Was currently being seen for palliative care. The need to ensure service plans reflected residents' current needs was reviewed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Travel RN) on 04/26/23 at 10:30 am. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 08/2021 with diagnoses including spinocerebellar ataxia (inherited brain disorder). The service plan available to staff dated 04/12/23, temporary service plans, and progress notes dated 01/24/23 through 04/22/23 were reviewed. Interviews with care staff and Resident 5 were conducted and observations were made. The resident's service plan was not reflective nor did it provide clear caregiving instruction in the following areas: * Supportive devices; and * Fall prevention interventions. The need to ensure service plans were reflective of the residents' care needs and provided clear caregiving instruction was discussed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Travel RN) on 04/26/23. They acknowledged the findings. 4. Resident 6 was admitted to the facility in 09/2019 with diagnoses including edema, history of falls, major depressive disorder and anxiety disorder. a. The current service plan dated 09/27/22 had not been updated quarterly. b. The current service plan dated 09/27/22 and temporary service plans from 01/24/23 to 04/07/23 were reviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas: * Home health PT/OT services; * Motorized wheelchair use; * Substance abuse; * Nail care; * Cleaning and supply ordering for CPAP/BiPAP machine (for breathing); * Fall history; * Fall interventions; * Use of transfer pole; * Significant weight change; and * Wound care. The need to ensure service plans were completed quarterly, were reflective of residents' current needs, and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Traveling RN) on 04/26/23 at 11:15 am. They acknowledged the findings.

1. Residents #s 2, 3, 5 and 6, Person Centered Service Plans have been corrected and reflect each of these resident's current care needs. 2. All Service Plans for current resident population are under review and will be brought to current status on or before compliance date of 6/25/23. New admission's service plans will be completed prior to move-in,within 30 days of move-in and then quarterly and with significant change. 3. A Service Plan Team has been established and will schedule timely review of service plans on a weekly ongoing basis from this date forward for a period of 8 weeks then will meet monthly thereafter. A Service Plan Binder will be created and all residents will be divided into 1 of 4 weeks each month for review of select residents weekly within said month. All Service Plans are scheduled quarterly or immediately with any significant change. All changes to service plan will be made as needed. 4. The community Executive Director is responsible for  the implementation of services.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs and provided clear direction regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 moved into the facility in 03/2014 with diagnoses including hypertensive heart disease with heart failure. Observations of the resident, resident and staff interviews and review of the service plan, dated 05/23/23 showed the service plan was not reflective of the resident's current care needs or did not provide clear direction to staff in the following areas: * Use of recliner for sleep; * Use of side rails for bed mobility; * Use of transfer pole for transfer; * Use of raised toilet seat; * Transfer status; and * Ambulation status. The need to ensure Resident 7's service plan was reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Corporate Traveling RN)  on 08/24/23 at 10:30 am. He reviewed the service plan and acknowledged the findings. 2. Resident 1 was admitted to the facility in 04/2007 with diagnoses including Cerebral Palsy and insomnia. Interviews with the resident and staff during the survey on 08/23/23 and 08/24/23, revealed the service plan dated 07/24/23, was not reflective in the following areas: * Use of bilateral siderails instead of bed halos on his/her bed for bed mobility; * Assistance needed with incontinence briefs; * Assistance needed with oral care; and * Fall interventions related to wearing non-skid socks. The need to ensure Resident 1's service plan was reflective of current needs and provided clear instruction was reviewed with Staff 2 (Corporate Traveling RN) on 08/24/23 at 12:15 pm. He acknowledged the findings.

1. Residents #1, and 7. Person Centered Service Plans have been corrected and reflect each of these resident's current care needs. 2. All Service Plans for current resident population are under review and will be brought to current status on or before 10/08/23.  New admission's service plans will be completed prior to move-in, within 30-days of move-in and then quarterly and with significant change of condition. 3. A Service Plan Team has been established and will schedule timely review of service plans on a weekly onging basis from compliance date forward, and then will meet monthly thereafter. A Service Plan Binder will be created and all residents will be divided into 1 of 4 weeks each month for reiew of select residents weekly within said month.  All Service Plans are schedule quarterly or immediately with any significant change. All changes to service plan will be made as needed. 4.  The community Executive Director is responsible for the implementation of services.

2. Resident 9 was admitted to the facility in 06/2022 with diagnoses chronic obstructive pulmonary disease, chronic kidney disease, edema, and asthma. The resident's service plan, dated 04/12/23, Interim Service Plans, and progress notes dated 10/08/23 through 12/06/23, were reviewed. Resident 9 and Staff 18 (CG) were interviewed. The service plan was not reflective of the resident's care needs and lacked a clear description of who would provide the services and what, when, how, and how often the services would be provided in the following areas: * Showering assistance; * PRN assistance with socks and shoes; * Monitoring of edema, including where the resident's edema was primarily located; * Where s/he takes his/her meals; * When to increase fluids and when to decrease fluids; * Oxygen use including who changed the concentrator tubing and filters and how often, portable tank use, and which company to go through for replacement parts and repair; * How to monitor the side rails and who to contact if they were in disrepair; * How to monitor the resident relating to the ability to disengage the seatbelt on his/her electric wheelchair; * What type of assistance the resident would need in case of an evacuation; * Assistance needed to re-charge the battery for the electric wheelchair; * Who would take care of Resident 9's cat when s/he was out of the building; * Ability to self direct PRN medications; and * Who to contact when s/he was in need of foot care. There was no documented evidence the service plan had been updated quarterly. The need to ensure the resident's service plan was reflective of current care needs, provided clear instruction to staff which included who would provide the services and what, when, how, and how often the services would be provided, and that the service plan be updated quarterly was discussed with Staff 2 (Corporate Traveling RN), Staff 19 (LPN), Staff 23 (RCC), and Staff 24 (Vice President of Operations) on 12/08/23. They acknowledged the findings. 3. Resident 10 was admitted to the facility in 12/2021 with diagnoses including a cerebral vascular accident (CVA), chronic pain and history of falls. Resident 10's most recent service plan was dated 02/23/23. There was no documented evidence the service plan had been reviewed and updated quarterly, as required. In an interview on 12/08/23, Staff 2 (Corporate Traveling RN)) and Staff 24 (Vice President of Operations) acknowledged Resident 10's service plan had not been updated quarterly. No further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services and were reviewed quarterly for 4 of 4 sampled residents (#s 9, 10, 11 and 13) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1.  Resident 11 was admitted in 03/2013 with diagnoses including osteoporosis. Review of 10/02/23 service plan and interim service plans (dated 10/06/23 through 12/08/23) and observations of the resident found the service plan was not reflective of the resident's current needs and lacked clear instruction to staff in the following areas: * Mobility, including use of manual wheelchair; * Transfers, including use of a transfer pole, and * Outside provider services.                                                                                                                                                                                                                                                                                                                                                                                            The need to ensure service plans were reflective of resident's needs and provided clear instruction to staff was discussed with Staff 2 (Corporate Traveling RN) and Staff 24 (Vice President of Operations) on 12/08/23. They acknowledged the findings 4. Resident 13 was admitted to the facility in 11/2012 with diagnoses including unspecified mental disorder due to known physiological condition and cerebral infarction. The service plan dated 12/06/23, Interim Service Plans, and progress notes dated 10/08/23 through 12/06/23 were reviewed. Interviews with care staff and Resident 13 were conducted and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas: * Spiritual and cultural interests; * Alcohol use; and * Weight status. The need to ensure service plans were reflective of the residents' care needs and provided clear caregiving instruction was discussed with Staff 2 (Corporate Traveling RN), Staff 19 (LPN), Staff 23 (RCC), Staff 24 (Vice President of Operations) and Staff 25 (President at Arete Living) on 12/08/23. They acknowledged the findings.

1. Residents #9, 10, 11, and 13's service plans have been updated to reflect resident's needs and preferences as well as clear instruction to staff. Service plans have been printed for all staff to review. 2. To prevent recurrance, all current resident service plans will be audited for accuracy and reprinted if needed for service plan binders. Direct care staff will be reeducated regarding the importance of reporting any questions or concerns related to resident service plans as well as reviewing all ISPs (Interim Service Plans) as part of shift change. A form was implemented for care staff to document any discrepancies between resident service plans and actual care needs. Form is to be turned into RCC (Resident Care Coordinator), LN or ED so that service plans can be updated and reflective. 3. ISPs will be reviewed at daily standup as part of the 24hr/72hr summary review and service plans will be updated as needed. Service plans will be evaluated and reviewed by all departments upon admission, at 30 days, quarterly and with significant change of condition. 4. The Executive Director will be responsible for maintaining this system, along with the Resident Care Coordinator and LNs.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, 4, 5, and 6's current service plans were reviewed during the survey. On 04/25/23 at 2:00 pm, Staff 2 (Corporate Traveling RN) confirmed the facility lacked documented evidence of a Service Planning Team to participate and review the individual service plans. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Regional VP of Operations) and Staff 2 on 04/26/23. They acknowledged the findings.

1. A Service Planning Team consisting of the Executive Director or designee, Licensed Nurse, care staff member, resident and/or resident's legal guardian and resident case managers as available has been established and will attend regular Service Plan meetings weekly for 4 weeks then monthly thereafter. 2 and 3. Service Planning Team will meet weekly for 4 weeks then monthly thereafter to review select residents on weekly rotation for needed updates or changes to resident's Service Plans. Advance notification will be provided to residents, resident's legal representative and/or any person of resident's choice along with resident case managers for individual Service Plan review. Any significant changes that result in service plan changes will be discussed with resident, resident's representative and case manager as necessary with updates to service plan immediately. Service Plan changes will be communicated with resident physician as necessary. Executive Director or designee and/or 4. Licensed Nurse to ensure corrections are complete and monitored thereafter.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which 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 who was going to provide services to the resident for 3 of 3 sampled residents (#s 1, 7 and 8). This is a repeat citation. Findings include, but are not limited to: Resident 1, 7 and 8's most recent service plans lacked evidence that 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 2 (Corporate Traveling RN) on 08/24/23. He acknowledged the findings. No further information was provided.

1. A Service Planning Team consisiting of the Executive Director or designee, Licensed Nurse, care staff member, resident and/or resident's legal guardian and resident case managers as available as been established and will attend regular Service Plan meetings weekly for 4 weeks then monthly thereafter. 2. and 3. Service Planning Team will meet weekly for 4 weeks then monthly thereafter to review select residents on weekly rotation for needed updates or changes to resident's Service Plans. Advance notification will be provided to residents, resident's legal representative and/or any person of resident's choice along with resident case managers for individual Service Plan review.  Any significant changes that result in service plan changes will be discussed with resident, resident's representative and case manager as necessary with updates to service plan immediately. Service Plan changes will be communicated with resident physician as necessary. Executive Director or designee and/or 4. Licensed Nurse to ensure corrections are completed and monitored thereafter.

Based on observation, interview and record review, it was determined the facility failed to develop interventions for short-term changes of condition, communicate the interventions to staff on each shift, and monitor the conditions with progress noted at least weekly through resolution for 3 of 5 sampled residents (#s 1, 5 and 6) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2007 with diagnoses including Cerebral Palsy (affects body movement and muscle coordination). a. Resident 1's current service plan noted s/he was dependent on staff for ADL care including floating heels while the resident was in bed and/or scooter as tolerated and repositioned every two to three hours while in bed. A progress note dated 01/27/23 noted a "callous on bottom of [left] heel some discoloration ..." There was no documented evidence actions or interventions were developed nor was there evidence the area had been monitored through resolution. During an interview on 04/25/23 at 12:45 pm, Staff 5 (LPN) stated she observed the resident's skin and noted there was no callous or discoloration. b. Progress notes dated 03/09/23 through 04/13/23 noted the following: * 03/09/23: " ...passing meds [resident] gagging and choking on food ...coughed a lot ....expelle [him/herself]"; * 03/14/23: " ...reported to nurse [resident] choking on food ...turning red...expelled [him/herself]"; * 03/24/23: " ...gagging and coughing a lot in hallway when swallowing food ...vomited small amount ..."; and * 04/13/23:"...talked to [resident] about need for easy to chew, bite size pieces regular diet with thin liquids..." In an interview with Resident 1 on 04/24/23 at 12:45 pm, s/he stated, " ...don't like cut up food all the time ...pick and choose when food is cut up ..." Resident 1 was observed during the noon meal on 04/25/23 and 04/26/23 to eat independently without coughing or choking on food or liquids. During an interview on 04/25/23 at 9:30 am, Staff 16 (Dietary) stated she worried about the resident and his/her ability to eat without choking.  Staff 16 stated she made sure the resident had plenty of liquid and that his/her food was cut up. Resident 1 experienced a change of condition related to swallowing and there was no documented evidence the facility determined what actions or interventions were required and there was no evidence the facility was documenting weekly monitoring through resolution. Resident 1's changes of condition and lack of interventions developed and weekly monitoring through resolution related to skin and swallowing were discussed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Traveling RN) on 04/26/23 at 10:15 am. Staff acknowledged the findings. 2. Resident 5 was admitted to the facility in 08/2021 with diagnoses including spinocerebellar ataxia (inherited brain disorder). Resident 5's service plan, progress notes and facility records dated 01/24/23 through 04/22/23 were reviewed and revealed the following changes of condition: a. The service plan noted the resident was at risk for falls. Progress notes and incident reports revealed non-injury falls occurred on 02/28/23 and 03/23/23. There was no documented evidence the facility determined and documented what action or interventions were needed for the resident with weekly monitoring noted until the conditions resolved. b. Progress note dated, 03/08/23 noted "Resident has a red, yellowish stage 1 pressure ulcer ..." There was no documented evidence the facility determined and documented actions or interventions were developed nor was there evidence the area had been monitored through resolution. Interviews with Staff 9 (CG) on 4/24/23 at 2:15 pm and Staff 12 (CG) on 4/25/23 at 1:20 pm confirmed they had observed the resident's skin and there was no redness or breakdown. The need for the facility to have documented evidence the facility determined and documented what action or interventions were needed for the resident with monitoring at least weekly until the changes of condition have resolved was discussed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Traveling RN) on 04/26/23. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 09/2019 with diagnoses including history of falling. The resident's progress notes dated 01/24/23 through 04/24/23, service plan, temporary service plan (TSP) and incident reports were reviewed. The following changes of condition was identified: The service plan noted the resident was at risk for falls. Interventions were in place to "remind resident to use pendant to call for assistance" and "staff to provide safety checks every round per shift." Progress notes and incident report revealed an injury fall occurred on 03/10/23 with a laceration to right scalp on 03/10/23 that required an ER visit and staples. There was no documented evidence the facility reviewed whether or not the resident had used the call light or when the last safety check was to determine if the interventions continued to be appropriate and effective. The need for the facility to have documented evidence the facility determined and documented what action or interventions were needed for the resident with monitoring at least weekly until the changes of condition have resolved was discussed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Traveling RN) on 04/26/23. They acknowledged the findings.

1. Resident # 1s chart has been updated with a significant change evaluation and will continue with weekly updates until resolved or new base line is established. Resident #5 and #6 changes of condition have resolved at this time and individual service plans have been updated to reflect their current care needs. 2. Staff will be inserviced at the next all staff meeting 06/07/23 to recognize changes of condition, report noted changes and document any changes in physical, mental or emotional status. 3. Licensed nurse will review documentation via Alert Charting and 24 hour report daily. 4. Licensed Nursing in community will be responsible to ensure corrections are complete and being monitored.

Based on interview and record review, it was determined the facility failed to monitor and document on the progress of short term changes of condition at least weekly until resolved for 1 of 3 sampled residents (# 7) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 7 moved into the facility in 03/2014 with diagnoses including hypertensive heart disease with heart failure. Resident 7's facility progress notes, dated 06/25/23 through 08/22/23, and incident reports, dated 07/07/23 through 07/21/23, were reviewed and revealed the following: * 06/25/23: A new open pressure ulcer on the bottom area; * 07/09/23: Skin tear on the left arm; * 07/21/23: A fall with "scattered bruising and skin tear"; * 07/28/23: "left lower arm bleeding with 3 skin tears"; and * 08/01/23: "bruising on the pant line approximately 5 inches and spot about 2 inches back thigh". There was no documented evidence the facility documented on the progress of the conditions at least weekly until resolved. The need to document on the status of the resident's condition at least weekly until resolved was discussed with Staff 2 (Corporate Traveling RN) on 08/24/23 at 10:30 am. He acknowledged the findings.

1. Residents #7 chart has been updated with a significant change evaluation and will continue with weekly updates until resolved or new baseline is established. 2. Clinical staff will be inserviced at a clinical staff meeting on 9.21.23 to recongnize changes of conditions, report noted changes and document any changes in physical, mental and emotional status. 3. Clinical team will review documentation via Alert Charting and 24-hour report daily. 4. Licensed Nursing in community will be responsible to ensure corrections are completed and being monitored.

2. Resident 9 was admitted to the facility in 06/2022 with diagnoses of chronic obstructive pulmonary disease, chronic kidney disease, edema, and asthma. The resident's clinical record was reviewed. Resident 9 and staff were interviewed. The following changes of condition were identified: * 10/08/23 - Returned from the ER; * 10/22/23 - "Chest pain issues" and an unspecified medication change; * 11/05/23 - Change in bumetadine (for edema) dosage;   * 11/14/23 - Return from the hospital; * 11/15/23 - Fall; * 11/16/23 - Discontinuation of gabapentin (for pain) and myrbetriq (for overactive bladder); and * 11/22/23 - Interim Service Plan directed staff to monitor and report low blood pressure, the resident feeling "like passing out" and having pain. There was no documented evidence the facility determined resident-specific actions or interventions, communicated the actions or interventions to staff on each shift, or documented weekly progress through resolution related to the changes of condition. The need to ensure residents with changes of condition had actions or interventions determined, communicate the actions or interventions to staff on each shift, and there was documentation at least weekly through resolution was discussed with Staff 2 (Corporate Traveling RN), Staff 19 (LPN), Staff 23 (RCC), and Staff 24 (Vice President of Operations) on 12/08/23. They acknowledged the findings. 3. Resident 11 was admitted in 03/2013 with diagnoses including osteoporosis. and alcohol dependency. a. Review of the records revealed Resident 11 experienced the following short-term changes of condition: * 11/07/23 - Fall resulting in a bloody nose; * 11/08/23 - Intoxication; * 11/10/23 - Aggressive behaviors; * 11/20/23 - Intoxication; and * 11/20/23 - Missed medications. There was no documentation the facility developed actions or interventions, communicated the actions or interventions to staff on each shift, and monitored each condition with progress noted at least weekly through resolution for each of Resident 11's short term changes of condition. b. In addition,  review of Resident 11's weight records revealed the following: * 10/08/23 - 107.6 pounds; and * 11/06/23 - 101.4 pounds. Review of the record showed the resident experienced weight loss of 6.2 pounds, or 5.76% of his/her total body weight in one month, from 10/08/23 through 11/06/23. The weight loss constituted a significant change in condition. In a 12/07/23 interview, Staff 2 (Corporate Traveling RN) confirmed the facility lacked documented evidence the resident was evaluated and referred to the RN for assessment which included documentation of the change and updates to the service plan as needed. On 12/08/23 the facility reported Resident 11's weight as 106.2 pounds. The need to ensure the facility had a system to monitor each resident, refer significant changes of condition to the RN, determine and document what actions or interventions were needed for the resident's short term changes of condition, ensure actions or interventions were communicated to staff on each shift and documented, at least weekly, until the conditions resolved was discussed with Staff 2 (Corporate Traveling RN) and Staff 24 (Vice President of Operations) on 12/08/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed for a significant change of condition for 2 of 2 sampled residents who were reviewed for significant changes of condition related to weight loss (#s 11 and 13); and determine and document what actions or interventions were needed for the resident following a change of condition, communicate the actions or interventions to staff on each shift, document on the progress of the condition at least weekly until resolved, and ensure documentation was made part of the resident record, for 2 of 2 sampled residents who experienced short term changes of condition (#s 9 and 11). This is a repeat citation. Findings include, but are not limited to: 1. Resident 13 was readmitted to the facility in 11/2023 following a hospital stay for cerebrovascular accident (CVA). Resident 13's progress notes and facility records dated 10/08/23 through 12/06/23 were reviewed and revealed the following significant change of condition related to weight loss: Recorded weights for Resident 13 were noted on 10/23/23 as 170.68 pounds and on 11/07/23 the facility documented a weight of 151 pounds for Resident 13. This represented a weight loss of 11.18% in one month. A review of resident records and an interview with Staff 2 (Corporate Traveling RN) on 12/07/23 at 9:50 am confirmed the facility failed to evaluate the resident for weight loss, refer to the facility nurse, document the change, or update the service plan as needed as it related to the weight loss. A weight of 161 pounds for Resident 13 was documented on 12/06/23 which demonstrated a gain of 6.62%. The need to implement a system for responding to residents with significant changes of condition was discussed with Staff 2, Staff 19 (LPN), Staff 23 (RCC), Staff 24 (Vice President of Operations), and Staff 25 (President of Arete Living) on 12/08/23. They acknowledged the findings.

1. Residents #9,11 and 13 have been assessed by RN and service plans have been updated to include all relevant interventions and service plans have been reprinted for service plan binders. 2. To prevent recurrence, staff will be reeducated on our alert charting guidelines and when to notify the RN. 24/72 hour summary will be reviewed as part of daily standup meeting. When a change of condition is identified, the resident will be placed on alert charting and will be assessed by LN. Any changes to plan of care, including clear instructions, will be communicated to staff via either an ISP or a complete updated service plan depending on the necessary changes. When a change of condition is determined to be a significant change, the RN will be notified, and will complete a comprehensive nursing assessment, including any changes to the plan of care, and will monitor at least weekly until the resident returns to baseline or a new baseline is established. Interventions will be evaluated and updated as part of the weekly monitoring. 3. This system will be evaluated five days a week as part of daily stand up meeting. This system will further be evaluated monthly as part of the facility CQI process, which includes a review of all residents who require significant change of condition monitoring. 4. The Executive Director and RN are responsible for maintaining this system.

2. Resident 1 was admitted to the facility in 2007 with diagnoses including Cerebral Palsy (affects body movement and muscle coordination). Resident 1's service plan dated 04/19/23 noted the resident was dependent on staff for ADL care, had a history of swallowing difficulty, was able to eat independently and was to receive a special textural diet to reduce the risk of choking. The resident's weight records noted the following: * 01/09/23 - 192 pounds; * 02/09/23 - 197 pounds; * 03/10/23 - 168 pounds; * 04/07/23 - 172 pounds; and * 04/08/23 - 195.8 pounds. Between 2/2023 and 03/2023 Resident 1 lost 29 pounds or 14.72 % of his/her body weight.  Between 03/2023 and 04/2023 Resident 1 gained 27.8 pounds or 14.19 % of his/her body weight resulting in significant changes of condition. At the time of the survey, Resident 1 weighed 183.2 pounds which was 12.6 pounds from the last documented weight or 6.4% loss of his/her body weight. Progress notes reviewed between 03/2023 and 04/13/23 noted the resident experienced a change of condition related to episodes of gagging and choking on food. Speech therapy was initiated and noted discussion with the resident about cutting up food, easy to chew food and cutting up into bite size pieces. Resident 1 was observed during the noon meal on 04/25/23 and 04/26/23 to eat independently without coughing or choking on food or liquids and ate greater than 50% of his/her meal. The meal served on 04/25/23 was not cut up into bite sized pieces and the meat served on 04/26/23 was observed to be cut into bite sized pieces. Resident 1 experienced significant weight fluctuations between 03/2023 and 04/2023 and there was no documented evidence the facility RN had conducted a significant change of condition assessment which included documentation of findings, resident status, and interventions made as a result of this assessment. During an interview on 04/26/23 at 10:15 am, Resident 1's significant weight fluctuations were discussed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Traveling RN).  Staff 2 acknowledged the findings and stated a significant change of condition assessment had been initiated.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed and included documented findings, resident status and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 1 and 6) who experienced a significant change of condition. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 09/2019 with diagnoses including edema and unspecified cirrhosis of liver. Resident 6's service plan dated 09/27/22 noted the resident was able to eat independently and was independent with transfers and wheelchair mobility. Resident 6's weight records were reviewed and revealed the following: * 02/02/23 - 227.6 pounds; * 03/03/23 - 213 pounds; * 04/06/23 - 217 pounds; * 04/13/23 - 219 pounds; and * 04/20/23 - 219.2 pounds.   From 02/02/23 to 03/03/23, Resident 6 had a weight loss of 14.6 pounds or 6.4% of his/her body weight in one month. This change in weight was considered a severe loss and indicated a significant change of condition which required an RN assessment. On 04/25/23 at 10:55 am, an RN assessment for the significant change of condition was requested. Staff 5 (LPN) confirmed there was no RN assessment completed for Resident 6's severe weight loss. The need to ensure significant changes of condition were assessed by an RN and included findings, resident status and interventions made as a result of the assessment was discussed with Staff 1(Regional VP of Operations) and Staff 2 (Corporate Traveling RN) on 04/26/23. They acknowledged the findings, and no additional documentation was provided.

1. Resident # 1 has had a significant change evaluation and his service plan has been updated to reflect changes. Resident # 6 has had a significant change evaluation completed and her service plan has been updated to reflect changes. 2. Facility RN will complete timely asssesments based on any resident noted/reproted to have change in condition to include findings, resident status and interventions made as a result of the assessment. Any resident that experiences a significant change in condition will be evaluated, service plan updated and reviewed by the Service Plan Team within 48 hours. 3. Significant Changes will be reviewed weekly and documented on accordingly. Once resident returns to or establishes new baseline, the significant change evaluation will be resolved. 4. Facility RN and LPN will monitor to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN and the assessment included documentation of findings, the resident's status and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 1 and 7) reviewed for significant changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 1 was admitted in 2007 and had diagnoses which included Cerebral Palsy. In an acuity interview with Staff 3 (RCC) on 08/23/23 at 9:45 am, she stated the resident required full assistance for most ADLs and needed a lift for all transfers. During an interview with the resident on 08/23/23 at 4:40 pm, s/he stated s/he had a history of skin breakdown on his/her buttocks. S/he further stated that home health staff "comes out and takes a look" and staff routinely applied barrier cream. On 07/20/23, Staff 17 (LPN) documented a progress note and completed a facility "Skin Integrity Weekly RN/LN Monitoring" form indicating the resident had a "1.5 cm by 0.8 cm" open wound on his/her right buttock, and a "1 cm by 0.4 cm" open wound on his/her left buttock. The wounds 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 08/24/23 at 11:15 am, Staff 2 (Corporate Traveling RN) stated he reviewed the record but was unable to find a facility RN assessment of the wounds. The findings were acknowledged. 2. Resident 7 was moved into the facility in 03/2014 with diagnoses including hypertensive heart disease with heart failure. Resident 7's clinical records were reviewed and the following was identified: * 06/25/23: "a new open pressure ulcer stage 2"; and * 07/03/23: "applying bandage on buttocks, daily and when soiled." This represented a significant change of condition as the resident experienced a deviation in his/her heath or functional abilities. There was no documented RN assessment including findings, the resident's status, and interventions made as a result of the assessment. On 08/24/23 at 12:25 pm, Staff 2 (Corporate Traveling RN) confirmed that there was no RN assessment for the pressure ulcer. On 08/24/23, the need to ensure an RN assessment for the opened pressure ulcer was discussed Staff 2. He acknowledged the findings.

1. Resident #1 has had a significant change evaluation and his service plan has been updated to reflect changes. Resident #7 has had a significant change evaluation completed and her service plan has been updated to reflect changes. 2. Facility RN will complete timely assessments based on any resident noted/reported to have had a change in condition to include findings, resident status and interventions made as a result of the assessment.  Any resident that experiences a significant change in condition will be evaluated, service plan updated and reviewed by the Service Plan Team at next scheduled weekly meeting. 3. Significant Changes will be reviewed weekly and documented on accordingly.Once resident retutrns to or establishes new baseline, the significant change evaluations will be resolved. 4. Community RN and LPN will monitor to ensure compliance.

Based on observation, interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 2 of 3 sampled residents (#s 1 and 2) who received outside services. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2007 with diagnoses including Cerebral Palsy (affects body movement and muscle coordination). During the acuity interview on 04/24/23 at 9:30 am, Staff 3 (RCC) and Staff 4 (LPN) identified Resident 1 as receiving speech therapy. Resident 1's current service plan, weight records and progress notes dated 03/01/2023 through 03/31/23 were reviewed and noted the following: * History of swallowing difficulty; * Significant weight fluctuations; and * Documentation of multiple episodes of gagging and/or choking. An outside provider summary sheet noted the following recommendation for Resident 1, "...have [resident's] food cut up into uniform - about quarter-size-bite sized or chop food finely to facilitate easier self feeding." During an observation on 04/25/23 at 12:08 pm, Resident 1 was served spaghetti with meatballs that was not cut up or finely chopped. Resident 1 did not cough or choke during the lunch observation. Resident 1 was identified to have episodes of gagging/choking and a history of swallowing difficulty and had speech therapy. There was no documented evidence the recommendation made by the outside service provider had been communicated to staff nor was the service plan updated. Reviewing and following up with outside provider recommendations was discussed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Traveling RN) on 04/26/23 at 10:15 am.  Staff acknowledged the findings. 2. Resident 3 was admitted to the facility in 08/2012 with diagnoses including Alzheimer's dementia. Resident 3 was identified during the acuity interview on 04/24/23 as receiving palliative care. * An Outside Provider Summary Sheet from the palliative care RN dated 02/23/23 included, "Reposition PRT [patient] q [every] 2 hours to avoid undue pressure on buttocks" and "float heels while in bed." The facility lacked documented evidence the recommendations were followed. The need to have a system for coordinating on-site services with outside providers was discussed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Traveling RN) on 04/26/23. They acknowledged the findings. No further information was provided.

1. Resident # 1 has been seen by Speech Therapy and has a diet of IDDSI #6. Soft and bite sized foods with moisture has been added to Service Plan. Resident # 3 remains on palliative care and her service plan has been updated to include her current care needs. 2. The community will assist in the scheduling of appointments and transportation with outside/off-site providers for all residents that require/request assistance and do not self-manage scheduling of appointments and transportation. Upon completion of outside appointments, returning residents are encouraged to provide any documention in relation to appointment, for any new orders or service changes to be made. 3. Licensed nurses or Medication Technician will obtain post visit documentation from providers for said resident's records if resident will not/is not able to provide information. Service plans will be updated accordingly as necessary based of provider documentation. This proces will be added to the monthly CQI meeting for review and follow-up. 4. Licensed nursing/Medication Technicians will monitor and manage outside service providers and coordination of care.

2. Resident 7 moved into the facility in 03/2014 with diagnoses including hypertensive heart disease with heart failure. During the acuity interview on 08/23/23, the resident was identified to receive HHRN services from an outside provider. Resident 7's clinical records, including recommendations, revealed the following: * 06/23/23: "Please keep the bandage in place"; and * 07/13/23: "Please assist with applying just bandage on buttocks. Daily and when soiled .". There was no documented evidence the facility coordinated care with HHRN and updated the service plan as necessary. The need to ensure the facility was reviewing outside service provider notes that were left in the facility and coordinated care with the onsite HHRN was reviewed with Staff 2 (Corporate Traveling RN). He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 2 of 3 sampled residents (#s 1 and 7) who received outside services. This is a repeat citation. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2007 with diagnoses including Cerebral Palsy and insomnia. Resident 1's current service plan and progress notes dated 06/25/23 through 08/23/23 were reviewed and noted the following: * Progress note on 08/14/23 stated the home health nurse would follow up with resident for a "Stage 1 wound on buttock. She offered occupational therapy services for resident as she observed caregiver transfer from sit and stand to wheelchair." * On 08/23/23 an interview with Resident 1 indicated s/he was receiving HH services related to wound care to his/her buttocks. On 08/23/23 no outside provider notes corresponding to this episode of care could be found in the resident's records. * On 08/24/23 at 11:30 am the surveyor requested outside provider notes for review. Staff 3 (Resident Care Coordinator) stated that she was not sure if Resident 1 was still receiving HH services or not and was not able to provide outside provider notes. * On 08/24/23 at 12:05 pm Staff 3 stated that she spoke to the HH clinician and Resident 1 was last seen on 08/22/23 but "forgot to leave the outside provider note." Staff 3 was unable to provide information on when HH services started, what discipline(s) were involved, and the frequency. No further information was provided. The need to have a system for coordinating on-site services with outside providers was discussed with Staff 2 (Corporate Traveling RN) on 08/24/23. He acknowledged the findings.

Resident #7 skin tears have been resolved and service plan has been updated to include her current care needs. 2. The community will assist in the scheduling of appointments and transportation with outside/off-site providers for all residents that require/request assistance and do not self-manage scheduling of appointments and transportation. Upon completion of outside appointments, returning residents are encouraged to provide any documention in relation to appointment, for any new orders or service plan changes to be made. 3. Licensed nurses or Medication Technician will obtain post visit documentation from providers for said resident's records if resident will not/is not able to provide information. RCC will call provider for any visit notes related to outside provider care received. Service plans will be updated accordingly as necessary based on provider documentation. This process will be added to the monthly CQI meeting for review and follow-up. 4. Licensed nursing/Medication Technicians will monitor and manage outside service providers and coordination of care.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 2 of 6 sampled residents (#s 2 and 3) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 01/2021 with diagnoses including diabetes and HTN. Resident 2's MAR/TAR, dated 04/01/23 through 04/24/23 and corresponding progress notes and prescriber orders were reviewed and revealed the following: Resident 2 was receiving metoprolol 50 mg, give 0.5 tablet by mouth at bedtime related to hypertension. Hold if systolic blood pressure (SBP) was less than 110 and notify the PCP if held. On 04/07/23 and 04/14/23 the SBP was 101 and 104 respectively and the medication was held. There was no documented evidence the PCP was notified that the medication was held. The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Traveling RN) on 04/26/23. They acknowledged the findings, and no additional information was provided. 2. Resident 3 was admitted to the facility in 08/2012 with diagnoses including Alzheimer's dementia and constipation. Resident 3's MAR/TAR, dated 04/01/23 through 04/24/23 and corresponding progress notes and prescriber orders were reviewed and revealed the following: a. Resident 3's MAR included "Ok to Crush medications and Give with food or water." The current signed orders dated 03/06/23 did not include an order to crush medications. b. The resident had a 03/06/23 physician's order for the facility to administer docusate sodium 100 mg capsule by mouth every other day and one PRN. The resident's MAR revealed the PRN had been added, but the routine was not included on the MAR. The need to ensure medications were carried out as prescribed and written physician orders were documented in the resident's facility record was discussed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Traveling RN) on 04/26/23. They acknowledged the findings, and no additional information was provided.

1. Resident #s 2 and 3 medication/orders will be reviewed and clarified by prescribing physician along with obtaining physician signatures. All medication and treatment orders will be carried out as prescribed. 2. Medication Technicians/Licensed nurse will complete triple check process with each new order and document in the resindent's record for all medications and/or treatments that the facility is responsible to administer. 3. Medication Technicians and nurses will review procedures regarding physicians or legally recognized practitioners are only ones authorized to make changes to a medication or treatment order. If a prescriber provides an order that isn't clear, said order will be submitted for clarification immediately. 4. Medication Technicians and Licensed nurses will be responsible for maintaining/documenting all physician orders for those that are managed by the facility staff.

2. Resident 1 moved into the facility in 2007 with diagnoses which included Cerebral Palsy. Physician orders, MARs and TARs for Resident 1, reviewed from 08/01/23 thorough 08/24/23, revealed the following orders were not followed: * Flonase nasal spray (for cough) two sprays in both nostrils once a day was not administered on one occasion; * Weekly weights every Friday for weight loss were not obtained; * Azelastine HCL (for allergies) nasal spray twice a day in each nostril was not administered on one occasion; and * Diclofenac Sodium Ophthalmic (for eye pain) one drop in both eyes four times a day was not administered on one occasion. On 08/24/23 at 10:15 am, the surveyor and Staff 16 (MT) observed/checked the MARs and medication supply. Staff 16 was unable to verify if the above orders had been followed. The need to ensure orders were carried out as prescribed was reviewed with Staff 2 (Corporate Traveling RN) on 08/24/23 at 12:15 pm. He reviewed the MARs with the surveyor and acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 7) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 moved into the facility in 03/2014 with diagnoses including pain in hip, shoulders and arms. The resident's 08/01/23 through 08/23/23 MAR/TAR, facility progress notes dated 06/25/23 through 08/22/23, and physician's orders were reviewed and identified the following: a. A physician order, dated 07/13/23, indicated to have knee brace for both knees. There was no documented evidence the order was transcribed to the MAR/TAR, and no evidence staff were following it. b. The MAR/TAR showed the following treatments: * Prevident Gel 1.1% application for oral care as needed; and * Foam dressing on buttocks as needed. There was no signed physician orders for the treatments in the resident's records. c. A physician order, dated 06/13/23, indicated to discontinue PRN acetaminophen and to start acetaminophen 1000 mg three times daily. * The MAR/TAR showed the PRN acetaminophen was continued on the MAR/TAR. * A 07/12/23 progress note indicated the PRN acetaminophen was administered to the resident which should have been discontinued. The need to ensure the facility followed physician orders was discussed with Staff 2 (Corporate Traveling RN) on 08/24/23. The findings were acknowledged.

1. Resident #s 1 and 7 medication/orders will be reviewed and clarified by prescribing physician along with obtaining physician signatures. All medication and treatment orders will be carried out as prescribed. 2. Medication Technicians, RCC and Licensed nurses will complete triple check process with each new order and document in the resident's record for all medications and/or treatments that the facility is responsible to administer. 3. Medication Technicians, RCC and Licensed nurses will review procedures regarding physicians or legally recognized practitioners are only ones authorized to make changes to a medication or treatment order. If a prescriber provides an order that isn't clear, said order will be submitted for clarification immediately. 4. Medication Technicians, RCC and Licensed nurses will be responsible for maintaining/documenting all physician orders for those that are managed by the facility staff.

2. Resident 9 was admitted to the facility in 06/2022 with diagnoses of chronic obstructive pulmonary disease, chronic kidney disease, edema, and asthma. Resident 9's MARs dated from 11/01/23 through 12/06/23, physician's orders, and the resident's clinical record were reviewed. The following was identified: a. The resident had a physician's order to be weighed daily. There was no documented evidence Resident 9 was weighed on: * 10/09/23; * 10/28/23 through 10/30/23; * 11/06/23; * 11/09/23; * 11/24/23; and * 12/04/23. b. Resident 9's physician ordered the facility to notify her of oxygen saturation levels if below 90%. On 12/06/23, staff documented a saturation level of 85%. There was no documented evidence the physician was notified. c. There were multiple blanks on the MAR with no documented evidence if the resident received medications or treatments on the following days: * 11/06/23 - weight; * 11/13/23 - vitals, bumetanide (for edema), duloxetine (for anxiety); magnesium (for bone maintenance), Miralax (for constipation), mybetriq (for overactive bladder), gabapentin (for pain), calcium (for heartburn), hydromorphone (for pain), spironolactone (for high blood pressure), buspirone (for anxiety), and weights; * 11/18/23 - Miralax; * 11/26/23 - Advair (for shortness of breath); and * 11/28/23 - Advair. The need to ensure physician's orders were followed was discussed with Staff 2 (Corporate Traveling RN), Staff 19 (LPN), Staff 23 (RCC), and Staff 24 (Vice President of Operations) on 12/08/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 2 of 4 sampled residents (#s 9 and 10) whose orders were reviewed. This is a repeat citation. Findings include, but not limited to: 1. Resident 10 was admitted to the facility in 12/2021 with diagnoses including a cerebral vascular accident (CVA) and chronic pain. Resident 10's 11/01/23 through 12/06/23 MARs and progress notes from 11/01/23 through 12/06/23 revealed the following medication was not administered as prescribed due to the medication not being available: Hydroxyzine (a medication to treat anxiety) 25 mg three times daily, not administered 18 times. On 12/08/23 the physician orders, the MAR, and progress notes were reviewed with Staff 2 (Corporate Traveling RN) and Staff 24 (Vice President of Operations). They acknowledged the findings.

1. Physician orders for residents #9 and 10 have been reviewed as well as record of administration and any omissions or missed notifications to provider. Weekly audit has been initiated to track omissions on administration record as well as any medication not in stock. Parameter audit has been updated to include all physician orders that have parameters. 2. To prevent recurrance, eMAR administration progress notes will be reviewed as part of the 24/72 hour report five days a week which includes a review of any medications out of stock.  Clinical team will follow up with pharmacy to resolve any issues resulting in delay of medication delivery and will notify Provider of any complications that result in medication not being administered as ordered. Medication administration audit report will be reviewed at least weekly to identify any omissions on administration record. Ongoing education will be provided to medication aides as needed based on findings of audits. 3. Medications not in stock will be reviewed five days a week as part of standup meeting. Omissions on administration record will be reviewed weekly, followed up on, and corrections documented as needed. Parameter Audit will also be reviewed weekly to ensure parameters are being followed and providers are being notifed.   4. The Executive Director will be responsible for maintaining this system, along with Resident Care Coordinator and LNs.

2. Resident 2 was admitted to the facility in 01/2021 with diagnoses including diabetes and HTN. Resident 2's physicians orders and 04/01/23 through 04/24/23 MARs were reviewed. Staff documented Resident 2 refused the following medications: * Metoprolol (for HTN) on 04/11/23; and * Losartan (for HTN) on 04/10/23. There was no documented evidence the facility notified Resident 2's physician of the refusals. On 04/26/23, the need to ensure the facility notified physicians or practitioners of refusals was reviewed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Traveling RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 2 of 2 sampled residents (#s 2 and 6), who had documented medication and treatment refusals. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 09/2019 with diagnoses including edema. The resident's 04/01/23 through 04/24/23 MAR and TAR were reviewed and revealed medication refusals for Toresemide 20 mg (for edema) on the following dates: * 04/12/23; * 04/13/23; and * 04/17/23. During an interview on 04/25/23 at 2:10 pm, Staff 3 (RCC) confirmed there was no documentation that the facility notified the physician or practitioner of the refusals.   On 04/26/23, the need to notify the physician or practitioner when a resident refused consent to orders was discussed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Traveling RN). They acknowledged the findings.

1. Resident #s 2 and 6 contnue to exercise their rights to refuse medications. Each refusal will be documented in the MAR and their physician will be notified by phone or fax of the refusal. 2. Medication Technicians will be inserviced on the proper procedure of documenting resident refusals at the all staff meeting on 06/09/23. 3. RCC and LPN will complete weekly audits x 4 then ongoing monthly to verify that refusals are being documented and physician notified timely. 4. RCC and LPN will monitor and ensure that corrections are completed.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 2 of 2 sampled residents (# 7 and 8), who had documented medication and treatment refusals. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 01/2023 with diagnoses including osteoporosis and hypertension. Resident 8's physicians orders and 08/01/23 through 08/23/23 MARs were reviewed. Staff documented Resident 8 refused the following: * Cholestyramine (for diarrhea) seven times; and * Ascorbic Acid (for vitamin deficiency) once. There was no documented evidence the facility notified Resident 8's physician of the refusals. On 08/24/23, the need to ensure the facility notified physicians or practitioners of refusals was reviewed with Staff 2 (Corporate Traveling RN) on 08/24/23. He acknowledged the findings. No further information was provided. 2. Resident 7 moved into the facility in 03/2014 with diagnoses including hypertensive heart disease with heart failure. Resident 7's physicians orders and 08/01/23 through 08/23/23 MARs were reviewed. Staff documented Resident 7 refused the following: * Bacitracin-Polymyxin treatment daily, 20 times; * Daily weight measurement, four times; and * Triple antibiotic treatment daily, 20 times. There was no documented evidence the facility notified Resident 7's physician of the refusals. On 08/24/23, the need to ensure the facility notified physicians or practitioners of refusals was reviewed with Staff 2 (Corporate Traveling RN). He acknowledged the findings. No further information was provided.

1. Resident #s 7 and 8 continue to exercise their rights to refuse medications. Each refusal will be documented in the MAR and their physician will be notified by phone or fax of the refusal. 2. Medication Technicians will be inserviced on the proper procedure of documenting resident refusals at the clinical staff meeting on 09/21/23. 3. RCC and LPN will complete weekly audits x 4 then ongoing monthly to verify that refusals are being documented and physician notified timely. 4. RCC and LPN will monitor and ensure that corrections are completed.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 1 of 1 sampled resident (#9), who had documented medication and treatment refusals. This is a repeat citation. Findings include, but are not limited to: Resident 9 was admitted to the facility in 06/2022 with diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, edema, and asthma. The resident's MARs dated from 11/01/23 through 12/06/23, physician's orders, and the resident's clinical record were reviewed. The following refusals were identified: * Bumetanide (for edema) on 11/17/23, 11/21/23, 12/03/23, and 12/04/23; * Advair (for shortness of breath) twice on 12/05/23; * Potassium (for low potassium) on 11/17/23; * Gabapentin (for pain) on 11/01/23; and * Daily weights on 11/24/23 and 11/30/23. There was no documented evidence Resident 9's refusals to consent to orders were communicated to the physician. The need to ensure the facility notified the physician or other legally recognized practitioner of medication and treatment refusals was reviewed with Staff 2 (Corporate Traveling RN), Staff 19 (LPN), Staff 23 (RCC), and Staff 24 (Vice President of Operations) on 12/08/23. They acknowledged the findings.

1. Resident #s 9's Administration Record has been reviewed and provider has been updated on all refusals to date. Resident #9 continues to exercise her right to refuse medications and treatments, however staff have been re-educated on the need to notify providers, unless there is an order that provider does not need to be notified. A list of resident's whose provider does not need to be notified, or any parameters on notifications has been posted in the med room for quick reference, and a fax coversheet has been implemented to save time on preparing faxes to providers. 2. To prevent recurrance, clinical staff will be reviewing 24/72 hour report at daily standup, which includes eMAR administration notes related to medication or treatment refusals. When identified, clinical team will verify that provider was notified, unless there is an order that states provider does not need to be notified. Clinical audit schedule has been updated to include a weekly audit of medication/treatment refusals and notification to providers.    3. This system will be evaluated weekly with medication/treatment refusal audit, and results of weekly audits will be reviewed monthly as part of the CQI process. 4. The Executive Director will be responsible for maintaining this system, along with the Resident Care Coordinator and LNs.

2.  Resident 1 was admitted to the facility in 2007 with diagnoses including Cerebral Palsy (affects body movement and muscle coordination). Review of the record indicated Resident 1 was prescribed lorazepam 1 mg every day as needed for anxiety. Non-drug interventions had been identified on the MAR. The MAR, reviewed between 04/01/23 and 04/24/23, noted staff administered the lorazepam PRN eleven times. There was no documented evidence the staff attempted non-drug interventions with ineffective results prior to administering the medication. The need to ensure non-drug interventions had been attempted and documented as ineffective prior to administration was reviewed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Traveling RN) on 04/26/23. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure staff attempted non-pharmacological interventions and documented they were ineffective prior to administering PRN psychotropics for 2 of 2 sampled residents (#s 1 and 6) who were prescribed PRN psychotropics. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 09/2019 with diagnoses including anxiety disorder. The resident's 04/01/23 through 04/24/23 MARs and signed physician orders were reviewed. The resident was prescribed trazodone HCl 12.5 mg as needed for acute anxiety, do not exceed more than four doses daily. There were three non-pharmacological interventions to attempt prior to administration. Resident 6 was administered trazodone on four occasions in April 2023. There was no documented evidence non-pharmacological interventions were attempted on the following dates: * 04/13/23 am; * 04/13/23 pm; and * 04/17/23 am. In an interview on 04/25/23 at 2:25 pm, Staff 3 (RCC) confirmed there were non-pharmacological interventions to offer Resident 6 but were not documented on 04/13/23 and 04/17/23. The need to document that non-pharmacological interventions were attempted without success prior to administering a PRN psychotropic medication was discussed with Staff 1 (Regional VP of Operations) and Staff 2 (Corporate Traveling RN) on 04/26/23. They acknowledged the findings.

1. Medication Technicians/Licensed nurses will be inserviced on findings in relations to Tag C330 on 06/07/23 at Med-Tech/LN portion of all staff meeting. 2. All residents on PRN psycotropic medications that affect mental function, behavior and experience will have their service plan updated to reflect non-pharmocological interventions to try prior to administration of psycotropic medications. Medication Technicians/ Licensed nurses will have documented evidence of each attempt of a non-pharmocologic intervention prior to drug administration. Residents have the right to refuse non-pharmocologic interventions and said refusals will be documented as well as notifcation of resindet's primary care physician. 3. This system will be evaluated monthly as part of the CQI process and will include a review of all MAR audits. 4. RCC, Medication Technicians and Licensed nurses will be responsible for monitoring and maintaining compliance.

Based on interview and record review, it was determined the facility failed to ensure staff attempted non-pharmacological interventions and documented they were ineffective prior to administering PRN psychotropics for 1 of 1 sampled resident (# 1) who was prescribed PRN psychotropics. This is a repeat citation. Findings include, but are not limited to: Resident 1 was admitted to the facility in 04/2007 with diagnoses including Cerebral Palsy and insomnia. Review of the record indicated Resident 1 was prescribed the following PRN psychotropic medications: Lorazepam 1mg every 24 hours PRN for anxiety; and Zolpidem tartrate 100mg every 24 hours PRN for sleep. Non-drug interventions had been identified on the service plan. The MAR, reviewed between 08/01/23 and 08/24/23, noted staff administered the lorazepam PRN 10 times and zolpidem PRN 20 times. There was no documented evidence the staff consistently attempted non-drug interventions with ineffective results prior to administering the medication. The need to ensure non-drug interventions had been attempted and documented as ineffective prior to administration was reviewed with Staff 2 (Corporate Traveling RN) on 08/24/23. He acknowledged the findings.

1. Medication Technicians/Licensed nurses will be inserviced on findings in relations to Tag C330 on 09/21/23 at clinical staff meeting. 2. All residents on PRN phsycotropic medications that affect mental function, behavior and experience will have their service plan updated to reflect non-pharmocological interventions to try prior to administration of phsycotropic medications. Medication Technicians/ Licensed nurses will have documented evidence of each attempt of a non-pharmocologic intervention prior to drug administration. Residents have the right to refuse non-pharmocologic interventions and said refusals will be documented as well as notifcation of resindet's primary care physician. 3. This system will be evaluated monthly as part of the CQI process and will include a review of all MAR audits. 4. RCC, Medication Technicians and Licensed nurses and ED will be responsible for monitoring and maintaining compliance.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to: The ABST must address all the required ADLs for each resident and the amount of staff time needed to provide care. The facility tool did not include updated information in all areas for each resident. The need to use an ABST that addressed all the ADLs for each resident and the amount of staff time needed to provide care, was discussed with Staff 1 (Regional VP of Operations) and Staff 2 (corporate Traveling RN) on 04/26/23.

1. A complete review of all residents for the ABST is in process and will be completed so that all current residents have been updated on the ABST to address all ADL's for each resident and the amount of actual time required for staff to complete cares. 2. ABST has been assigned to licensed nurses to monitor for changes or additions as necessary and will be reviewed and completed prior to resident move-in with changes made within 30 days to address resident needs and/or to reflect any significant change of condition. 3. The ABST will be maintained/updated during each scheduled resident's service plan review every quarter and/or with significant change. This will also be added to the monthly CQI process. 4. Licensed Nurses with access to the online tool will be responsible to ensure the ABST is current and up to date.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to: On 08/23/23, the ABST was reviewed and identified the following: * The ABST reflected two residents who were no longer residing in the facility; * One unsampled resident, who resided in the facility, was not entered into the ABST; * One unsampled resident, newly admitted, was created in the ABST, but there was no data entered to the ABST including the amount of staff time needed to provide care in each task; and * One sampled resident's, Resident 7, ABST was not updated quarterly as required. The need to ensure the facility's ABST was updated when residents moved in or out, and no less than quarterly was reviewed with Staff 2 (Corporate Traveling RN) during the exit interview on 08/24/23. He acknowledged the findings.

1. A complete review of all residents for the ABST is in process and will be completed so that all current residents have been updated on the ABST to address all ADL's for each resident and the amount of actual time required for staff to complete cares. 2. ABST has been assigned to licensed nurses and ED to monitor for changes or additions as necessary and will be reviewed and completed prior to resident move-in with changes made within 30-days to address resident needs and/or to reflect any significant change of condition. 3. The ABST will be maintained/updated during each scheduled resident's service plan review every quarter and/or with significant change. 4. Licensed Nurses and ED, will obtain access to the online tool will be responsible to ensure the ABST is current and up to date and ongoing.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to: On 12/07/23, the ABST was reviewed with Staff 23 (RCC) and identified the following: * Resident 10 and 13 had documented evidence of significant changes of condition. The ABST was not updated to reflect those changes and generate an accurate staffing plan; and * There was no documented evidence the ABST had been reviewed quarterly for Resident 9 and 11. The need to ensure the facility's ABST was updated whenever there was a significant change of condition and was reviewed no less than quarterly was reviewed with Staff 23 on 12/07/23. She acknowledged the findings.

1. ABST has been updated to reflect the significant change with residents #10 and 13, and has been updated for residents #9 and 11 as well.  ABST will be reviewed for every current resident to validate the accuracy of the ADL information. 2. To prevent recurrance, our admission checklist has been updated to include completing the ABST prior to admission. Additionally, our checklist for evaluation and service plan updates now includes checking off that the ABST has been updated. With these 2 system updates, that should ensure that the ABST is completed prior to resident move-in, with changes made within 30-days, Quarterly or with significant change of condition. 3. This system will be evaluated weekly until condition lifted for non-compliance, and then will be evaluated monthly as part of our CQI process. 4. The Executive Director, along with the Resident Care Coordinator will be responsible for maintainint this system.

Based on observation and interview, it was determined the facility failed to ensure all exterior walking surfaces were maintained in good repair. Findings include, but are not limited to: The facility's exterior grounds were toured with Staff 8 (Director of Maintenance) on on 04/26/23. The following deficiency was identified: There were drop-offs of up to four inches from asphalt to concrete along the edges of of the sidewalk adjacent to the garbage storage area. The drop-offs created a tripping hazard for residents. The need to ensure all exterior pathways and surfaces were in good condition and free from drop-offs was discussed with Staff 1 (Regional VP of Operations) and Staff 8 on 04/26/23. They acknowledged the findings.

1 and 2. To reduce the potential tripping hazard indicated, approval was granted to hire Plait Services to grind the concrete at the raised area of the sidewalk adjacent to the garbage storage area in efforts to reduce the drop off and making the area flush. 3. Once task completed, violation will not happen again. 4. Compliance will be maintained by ED and Director of Maintenance.

Based on observation and interview, it was determined the facility failed to ensure all exterior walking surfaces were maintained in good repair. This is a repeat citation. Findings include, but are not limited to: The facility's exterior grounds were toured with Staff 8 (Director of Maintenance) on 08/23/23. The following deficiency was identified: There were drop-offs of up to 2 inches from asphalt to concrete along the edges of  the sidewalk adjacent to the garbage storage area. The drop-offs created a tripping hazard for residents. The need to ensure all exterior pathways and surfaces were in good condition and free from drop-offs was discussed with Staff 2 (Corporate Traveling RN) on 08/24/23. He acknowledged the findings.

1 and 2.  The gap between new concrete at new side walk and ground has been filled in with gravel and sand to level. Exterior door idenified has been custom ordered to fit and will be professionally installed upon  arrival to meet regulation.  Should door not arrival prior to compliance date an extension will be filed with State. 3. Once task completed, violation will not happen again. 4. Compliance will be maintained by ED and Director of Maintenance.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to: The facility was toured on 04/24/23 and the following was observed: a. Exterior of building: * Bench to left of front entrance had chipped paint, splintered wood and was not cleanable; * Smoking area: ground, patio furniture, plastic cigarette receptacles and gazebo were covered in black and white matter and the front face to the fire extinguisher case was broken; * All patio furniture: front entrance, back porch and second floor patio surfaces had brown matter and stains on the cushions; * Second floor patio and wheelchair ramp was dirty and in need of cleaning; * Wooden planter box below second floor wheelchair ramp was decomposing and had a railroad spike protruding from its surface; * The area underneath the second floor patio had old window screens and ladders lying on the ground, door to the storage closet was rusted at the bottom and was missing a doorknob, and the exterior wall siding was covered in black matter; and * Back porch off dining room had debris, rust stains and peeling paint on the floor of the deck, cobwebs on the ceiling and the barbeque grill had a thick black and white substance on the interior and exterior. b. First Floor: * Two vents above the entryway to the dining room were dirty and in need of cleaning, buffet cabinets in the dining room were in need of cleaning, and cabinets doors were missing hardware; * Floor drain under buffet sink was full of dark brown matter; * Chair in dining room was missing a wheel; * Staff laundry room: floor was missing large pieces of linoleum in multiple places making the areas uncleanable, and multiple light fixtures had bulbs that were burned out; * Room 104 had damage to the wooden cabinet shelving and doors; and * Room 125 had black stains on the carpet throughout the room, black marks on the linoleum in bathroom, and the shower had black matter on the tile and peeling paint in the right upper corner of the wall. c. Second Floor: * Activity room had a large black stain on the carpet, and the kitchen area countertops and cabinets had surfaces with sticky substances and debris; * Resident laundry room doorway was missing a threshold strip and multiple light fixtures inside and directly outside of the room were missing covers;                                                                                                                                                                                                                                                                   * Two armchairs next to elevator had worn out armrests and stains on the seats; * Handrail across from elevator and Room 248 was loose; * Room 227 had black stains on the carpet throughout the room, damage to the wooden cabinet drawers and doors and gouges in the wall next to the bathroom entrance; and * Room 250 had black stains on the carpet throughout the room. d. Facility Wide: * Scuff marks on multiple exit doors. The need to ensure the interior and exterior of the building was clean and maintained in good repair was discussed with Staff 1 (Regional VP of Operations) and Staff 8 (Director of Maintenance) on 04/26/23 at 9:08 am. They acknowledged the findings.

1. A complete walkthrough of the community was completed and all areas identified during survey and listed under C613 regarding the areas needing cleaning and/or repair will be completed no later than 06/25/23. 2. To prevent recurrance, Maintenance Director will conduct a weekly walkthrough of the community and will identify any areas needing cleaning/repair. Weekly walkthrough will be reviewed at standup meeting and a plan will be put into place to correct any of the identified items. 3. Completion of weekly walkthrough tasks will be reviewed monthly as part of the community's CQI process. 4. Maintenance Director and Executive Director are responsible for maintaining this system.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. This is a repeat citation. Findings include, but are not limited to: The facility was toured on 08/23/23 and the following was observed: a. Exterior of building: * The area underneath the second floor patio had a door to the storage closet that was rusted at the bottom and was missing a doorknob; and * Barbecue grill on back porch off dining room had black substance and food debris on the interior surfaces. b. First Floor: * Room 104 had damage to the wooden cabinet shelving and doors; and * Room 111 had several large black stains on the carpet. c. Second Floor: * Activity room had several large black stains on the carpet; * Resident laundry room had two light bulbs burned out and the light fixture was missing a cover;                                                                                                                                                                                                                                                                   * Room 227 had black stains on the carpet throughout the room, damage to the wooden cabinet drawers and doors and gouges in the wall next to the bathroom entrance; and * Room 250 had black stains on the carpet throughout the room and was missing the threshold strip between the carpet and linoleum and was a potential tripping hazard. The need to ensure the interior and exterior of the building was clean and maintained in good repair was discussed with Staff 2 (Corporate Traveling RN) on 08/24/23. He acknowledged the findings.

1. A complete walkthrough of the community was conducted and all areas identified during survey and listed under C613 regarding the areas needing cleaning and/or repair will be completed no later than 10/08/23. 2. To prevent reocurrance, Maintenance Director, and ED will conduct a weekly walkthrough of the community and will identify any areas needing cleaning/repair. Weekly walkthrough will be reviewed at standup meeting and a plan will be put into place to correct any of the identified items. 3. Completion of weekly walkthrough tasks will be reviewed monthly as part of the community's Maintenance CQI process. 4. Maintenance Director and Executive Director are responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to immediately report abuse or suspected abuse to the local SPD office and implement measures necessary to protect residents and prevent the reoccurrence of abuse for 1 of 1 sampled resident (#11).  Findings include but are not limited to: Resident 11 was admitted to the facility in 03/2013 with diagnoses including alcohol dependence. Review of progress notes dated 10/08/23 and 11/06/23, Grievance Communication Forms and Incident Reports revealed the following: * 11/10/23 - Progress note: "[unsampled resident] informed me that [Resident 11] is upset with [him/her] and aggressively following [him/her] around the dining room and yelling at [him/her] in front of other residents and in hallways, calling [him/her] [multiple expletives] and when [s/he] tried to move around, [s/he] said 'where are you going snitch... you're not going anywhere... I'm not moving for you.' [S/he] is concerned for [his/her] safety"; and * 11/11/23 - Grievance Communication Form: " I have to ring my pendant just to leave my room to eat. I have never been afraid of anything and I refuse to live my life in fear, where I used to call home, is no longer safe for me." During an interview on 12/07/23 Staff 1 (Regional Vice President of Operations) reported she had investigated the incident and concluded abuse and neglect had been ruled out because the resident had not experienced physical abuse. There was no documented evidence the facility immediately reported the suspected abuse to SPD or took measures necessary to protect residents and prevent the reoccurrence of abuse. The need to immediately report abuse and suspected abuse to SPD and take measures necessary to protect residents and prevent the reoccurrence of abuse was discussed with Staff 2 (Corporate Traveling RN) and Staff 24 (Vice President of Operations) on 12/08/23. They acknowledged the findings. The facility was asked to report the incident to the local SPD office. Verification was obtained prior to survey exit.

1. APS was notified of the incident on 12/7/23. Service plans for resident #11 and unsampled resident were both updated to include behavioral interventions. 2. A training will be conducted with the entire management team to reeducate on abuse and neglect reporting guidelines. The abuse reporting and investigation guide will be used for this training, which includes definitions for all types of abuse, an interpretive guide including examples, and reporting responsibilities. All staff will receive training on abuse and neglect reporting guidelines upon hire and bi-annually thereafter, including the need for immediate notification to ED (Executive Director)/LN (Licensed Nurse)of any reported or suspected abuse or neglect. 3. All incident reports will be reviewed as part of daily standup meeting (5 days a week) and the reporting guidelines will be used to identify any reportable events.  Additionally the 24 hour report will be reviewed at standup, which includes a review of all progress notes written in the past 24 hours. On Mondays, the 72 hour report will be reviewed to include all documentation from the weekend. This would identify any progress notes written that indicate potential abuse or neglect, even if an incident report was not completed. As part of the monthly CQI (Continuous Quality Improvement) process, all incident reports will be reviewed, and reportable events will tracked to ensure reporting guidelines are being followed.    4. The Executive Director and will be responsible for maintaining this system, along with Resident Care Coordinator and LNs.

3. Resident 1 was admitted to the facility in 2007 with diagnoses which included Cerebral Palsy. Residents 1's MARs were reviewed from 08/01/23 through 08/24/23 and the following was noted: a. Lack of resident-specific instructions for multiple PRN pain medications, including which one to administer first. b. S/he had an order for docusate sodium (stool softener) 100 mg PRN for bowel care, and TUMs 500 mg 1 tablet PRN for heartburn. The MAR lacked frequency of administration for the medications. c. The resident had an order for Ondansetron HCL 4 mg one tablet every eight hours PRN nausea. However, the MAR instructed staff to administer 8 mg (twice the dosage), not 4 mg as ordered. d. The resident had an order for TUMs 200 mg one tablet three times a day as needed for heartburn. The MAR instructed staff to give 500 mg daily, not 200 mg as ordered. d. Resident 1 had orders for Zinc Oxide cream (for skin integrity) as needed at bedtime, and Nystatin powder as needed for dermatitis. The MARs instructed staff to apply the medications to "affected area". The MAR lacked resident-specific instructions for the application of the cream and powder. e. The resident had an order for compression stockings to lower legs be applied each morning and removed at night. In an interview on 08/23/23 at 4:40 pm, Resident 1 stated s/he did not wear the pressure stockings. According to the MAR/TAR, staff initialed that they applied the stockings in the morning and removed them at night. f. S/he had an order for Montelukast Sodium 10 mg 1 tablet at bedtime as an anti-inflammatory. According to the MAR, the medication was not administered on two occasions. On 08/24/23 at 10:15 am, the surveyor and Staff 16 (MT) observed/checked the MARs and medication supply. Staff 16 verified the medication had been given, but staff failed to document. The need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 2 (Corporate Traveling RN) on 08/24/23 at 12:15 pm. He reviewed the MARs with the surveyor and acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, had resident-specific parameters for PRN medications, and clear instructions to staff for 3 of 3 sampled residents (#s 1, 7 and 8) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 01/2023 with diagnoses including osteoporosis and hypertension. Resident 8's 08/01/23 through 08/23/23 MAR was reviewed and identified the following: Resident 8 was prescribed PRN Percocet (for pain), PRN oxycodone (for pain) and PRN Tylenol (for pain). The MAR lacked parameters instructing staff on which medication to use first. The need to ensure MARs had clear parameters and instructions for staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 2 (Corporate Traveling RN) on 08/24/23. He acknowledged the findings. 2. Resident 7 was moved into the facility in 03/2014 with diagnoses including pain in hip, shoulders and arms. Resident 7's 08/01/23 through 08/23/23 MAR was reviewed and identified the following: * Resident 7 was prescribed PRN Advair Diskus (for shortness of breath) and Albuterol Sulface (for shortness of breath). The MAR lacked parameters instructing staff on which medication to use first; * Resident 7 was prescribed PRN Benzonatate (for cough) and Guaifenesin syrup (for cough). The MAR lacked parameters instructing staff on which medication to use first; * Resident 7 was prescribed PRN Loperamide (for diarrhea) and Diphenoxylate-Atropine (for dairrhea). The MAR lacked parameters instructing staff on which medication to use first; * The MAR showed PRN acetaminophen (for pain), apply ice and heat pack (for pain) and Diclofenac sodium ointment (for pain). The MAR lacked parameters instructing staff on which medication to use first; * The MAR showed PRN Albuterol Sulface (for shortness of breath) 1-2 puffs. The MAR lacked parameters instructing staff on when to administer 1 puff versus 2 puffs of the inhaler; and * The MAR had multiple blanks. The need to ensure MARs had clear parameters and instructions for staff when more than one PRN medication was prescribed for the same condition and clear doses, were reviewed with Staff 2 (Corporate Traveling RN) on 08/24/23. He acknowledged the findings.

1. Resident 1, 7 and 8. Clinical staff will ensure MARs are accurate with specific parameters for PRN medications, and with clear instructions. 2. Accurate Medication Administration will be kept of all medications, including any over the counter medications for residents that we manage their medications. 3. Clinical staff will have a refresher training at the clinical staff meeting on 9/21/23. 4. Weekly monitored of the MARS will be conducted by RCC's, ED and Licensed nurses.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, had resident-specific parameters for PRN medications, and specific instructions to staff for 1 of 4 sampled residents (#9) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 9 was admitted to the facility in 06/2022 with diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, edema, and asthma. The resident's MARs dated from 11/01/23 through 12/06/23, physician's orders, and the resident's clinical record were reviewed. The following inaccuracies were identified: a. Resident 9's MAR directed staff to document his/her pain level prior to administering scheduled and PRN pain medications. Staff documented "N/A [not applicable]" for the following medications: * Scheduled hydromorphone on 11/02/23, 11/04/23, 11/05/23, 11/08/23, 11/17/23 though 11/19/23, 11/24/23 through 11/26/23, 12/02/23, and 12/05/23; and * PRN Tylenol on 11/27/23. b. Resident 9 had an order for PRN hydroxyzine (an antihistamine that also helps anxiety) which directed staff to utilize non-drug interventions prior to administration. There was no documented information the facility tried the non-drug interventions prior to administering the PRN: * 11/01/23 through 11/03/23; * 11/07/23; * 11/23/23, * 11/25/23, * 11/26/23, and * 12/02/23. c. There was no documented evidence of parameters to direct unlicensed staff on which PRN bowel medication to administer in what order for Miralax and Senna. d. There was documentation relating to Resident 9 being out in the hospital from 11/09/23 through 11/13/23. On 11/09/23, staff documented administering gabapentin (for pain) and magnesium (for bone maintenance) at 8:00 pm. On 11/10/23, staff documented administering Advair (for shortness of breath) between 4:00 pm and 5:00 pm. e. Staff documented administering diclofenac gel (for pain) on 11/03/23, 11/06/23, 11/09/23, and 11/13/23. Resident 9's record showed s/he self-administered the medication. The need to ensure MARs were accurate was reviewed with Staff 2 (Corporate Traveling RN), Staff 19 (LPN), Staff 23 (RCC), and Staff 24 (Vice President of Operations) on 12/08/23. They acknowledged the findings.

1. Resident #9's physician orders have been reconciled to ensure proper parameters in place for all orders. A complete audit was conducted of all PRN orders, including direction to unlicensed staff on which prn to use when applicable. The Parameter Audit Form was updated to include all required parameters. It was determined that the supplementary documentation requiring a pain level to be documented with scheduled pain medication was selected in error and not actually part of the physician order. 2. To prevent recurrance, all PRN orders will be audited monthly to ensure all PRNs have specific instructions for staff including which PRN to use when there are more than one with the same reason for use. When Licensed Nurses are signing off on triple checks for any new or changed PRN orders, they have also been re-educated on the importance of checking to see if resident has other PRNs with the same reason for use and updating the instructions as needed. 3. This system will be evaluated monthly as part of the facility CQI process, which includes a review of PRN medication audits. 4. The Executive Director, along with the Resident Care Coordinator and LNs will be responsible for maintaining this system.

Based on observation, interview, and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications and have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (#9) who chose to self-administer their medications. Findings include, but are not limited to: Resident 9 was admitted to the facility in 06/2022 with diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, edema, and asthma. The resident's MARs dated from 11/01/23 through 12/06/23, physician's orders, and the resident's clinical record were reviewed. The resident was interviewed. The record reflected Resident 9 self-administered Advair (for shortness of breath), albuterol (for shortness of breath), and diclofenac gel (for pain). The following was identified: * On 12/07/23 at 11:30 am, the resident confirmed self-administering diclofenac gel "depending on where I need it." Resident 9 explained needing assistance from staff to apply the gel with hard to reach areas on his/her body. * On 12/08/23 at 10:45 am, the resident confirmed s/he does not self-administer Advair and does self-administer albuterol. * There were physician's orders for Resident 9 to self-administer Advair and diclofenac gel, but no documentation relating to the albuterol. * There was no documented evidence the resident was evaluated to self-administer medications. The need to obtain physician's orders and complete the evaluation of the resident's ability to self-administer medications was discussed with Staff 2 (Corporate Traveling RN), Staff 19 (LPN), Staff 23 (RCC), and Staff 24 (Vice President of Operations) on 12/08/23. They acknowledged the findings.

1. Physician Orders for resident #9 have been reconciled and sent to PCP to review and sign, along with clarification on what resident is wanting to self administer. LN will complete a self med assessment once order is received from PCP to ensure accuracy between the MAR and the self med assessment. Evaluation and service plan will be updated at that time. Self med assessment will be updated quarterly and orders will be reconiled and sent to PCP for ongoing coordination of care. A complete audit will be done for current residents to ensure that any residents who are self administering medications have the required physicians order as well as a nursing assessment and that their evaluation and service plan is reflective of current status. 2. To prevent recurrance, an updated version of the Level of Care and Service Plan Evaluation in PCC (PointClickCare) has now been fully implemented for all current residents, as well as any future admissions. This evaluation will trigger a Self Medication Administration Assessment when any of the options are selected that indicate the resident self administers some or all of their medications or treatments. As part of the Self Medication Administration Assessment, the LN will verify that we have orders for the resident to self administer, and that our records match what the resident is actually taking. The Self Medication Administration Assessment will re-trigger every time the Level of Care and Service plan evaluation is completed to ensure it is updated at least quarterly or with a significant change of condition. 3. This system will be evaluated bi-annually as part of our CQI process. 4. The Executive Director, along with the LNs will be responsible for maintaining this system.

Based on observation, interview, and record review, it was determined the facility failed to ensure the relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 152, C 260, C 262, C270, C 280, C 290, C 303, C 305, C 330, C 361, C 610 and C 613.

C455 Acknowledged

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. This is a repeat citation. Findings include but are not limited to: Refer to C260, C270, C303, C305, C310, and C361.

C455 Acknowledged

The findings of the re-licensure survey conducted 04/24/23 through 04/26/23 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 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 revisit to the relicensure survey of 04/26/23, conducted 08/23/23 through 08/24/23, 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. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 04/26/23, conducted 12/06/23 through 12/08/23, 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 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 third revisit to the re-licensure survey of 04/06/23, conducted 04/10/24 through 04/11/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 01/26/23 the kitchen was observed to need cleaning and repair in the following areas: a. Food spills, splatters, debris, dust, dirt, and black matter was observed on, inside or underneath the following: * Floor throughout the kitchen including the dry storage area; * Stainless steel upper and lower shelves throughout the kitchen; * Entryway doors, door to dry storage area and walk-in refrigerator and freezer doors; * Wall between walk-in refrigerator and walk-in freezer; and * Pipe fittings and couplings next to the warewasher. b. The following areas and equipment were in need of repair: * Entryway doors had chipped paint and were un-cleanable; * Left wall in the dry storage area had holes in it; and * Seal to the walk-in refrigerator door was torn in several areas. c. Observations made during the survey revealed the following: Observations made of Staff 3 (Cook) prepping breakfast for the following day showed; * Staff 3 prepared bacon on a baking sheet with gloved hands; * While preparing the bacon, Staff 3 walked away from the prep area and carried a sheet of bacon to the walk-in refrigerator, grabbing the door handle with the gloved hands; * Staff 3 went back to the prep area without changing gloves or washing her hands; * Staff 3 was observed touching bacon with the same gloved hands. During the observation, Staff 3 did not change her gloves or wash her hands. On 01/26/23 at 2:26 pm, the surveyor shared the above observations with Staff 2 (Dining Services Director). She acknowledged the findings. On 01/23/26 at 3:43 pm, the surveyor discussed infection control practices with Staff 1 (ED). She acknowledged the findings. Review of the menu for the week of 01/22/23 revealed the facility offered over easy style eggs to residents daily. During an interview with Staff 2 at 2:37 pm, she confirmed the facility did not consistently use pasteurized eggs for egg dishes in which the eggs were not fully cooked. On 01/26/23 at 3:43 pm, the concern regarding using non pasteurized eggs in dishes where the eggs were not fully cooked was discussed with Staff 1 and Staff 2. They acknowledged the findings. The need to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 and Staff 2. They acknowledged the findings.

1. Kitchen was deep cleaned including all areas identified during the survey. Doors to walk-in/freezer and main kitchen door has been painted. A new seal for the freezer door has been ordered and will be replaced as soon as it comes in. 2. All dietary staff have been re-trained on proper procedures for changing gloves and washing hands before and during food preparation, We have placed signage in the prep area to ensure proper food sanatation practices are being followed reguarding the use of gloves and handwashing. Cleaning schedules have been implemented including daily, weekly and monthly cleaning duties to ensure cleanliness is maintained. All cooks have been re-trained regarding the use of pasturized eggs in any dishes that the eggs will not be cooked thoroughly and the Dietary manager will ensure that pasturized eggs are available when those items are on the menu. 3. This system will be evaluated monthly as part of our Continuous Quality Improvement program which includes a kitchen audit. 4. The Dietary Manager and Executive Director are responsible for maintaining this system.

The findings of the kitchen inspection, conducted 01/26/23, 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, Oregon Health Service Food Sanitation Rules.

The findings of the first revisit to the kitchen inspection survey of 01/26/23, conducted 04/24/23 through 04/26/23 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.

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 01/10/2023.  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 09/12/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 09/12/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 09/12/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day