Spring Meadows Assisted Living Facility

Based on interview and record review, it was determined the facility failed to ensure investigations of injuries of unknown cause and falls included all required information and reasonably concluded and documented the events were not the result of abuse for 1 of 2 residents (#1) who experienced injuries of unknown cause and falls. Findings include, but are not limited to:

Resident 1 moved into the community in 01/2021 with diagnoses including Alzheimer’s disease and was identified in the acuity interview as having a history of falls.

Review of the resident’s 05/08/25 change of condition evaluation noted the resident was a high fall risk and listed an intervention to “ensure resident has [four-wheeled walker] when ambulating.” Observation notes, incident reports, and investigations dated 03/13/25 to 06/09/25 were reviewed, and the following was identified:

* 05/27/25 – A progress note indicated resident had an unwitnessed fall, with no report of injury at time of incident, and the resident was unable to state what had happened;
* 05/27/25 – A progress note indicated resident reported, “some lower back pain”;
* 05/28/25 – A progress note indicated, “resident [sic] back was pretty painful for [him/her] this morning…has bruising on lower back [left] side”;
* 06/03/25 – A progress note indicated the resident had an unwitnessed “fall without injury,” and the resident was unable to state what had happened;
* 06/03/25 – An incident report indicated the resident had a left knee abrasion related to the fall; and
* 06/03/25 – A progress note stated, “Though reported as a [non-injury fall] resident did complain of some pain located to [his/her] lower back this shift.”

Facility investigations for the falls on 05/27/25 and 06/03/25 were reviewed. The facility did not reasonably conclude and document the incidents were not the result of abuse. There was no documented investigation of the bruise reported on 05/28/25 to determine if it was a result of the resident’s fall on 05/27/25.

The need to ensure investigations reasonably ruled out abuse for injuries of unknown cause and incidents of suspected abuse, or were reported to the local SPD office if abuse could not be ruled out, was discussed with Staff 1 (ED) at 10:40 am on 06/11/25. She acknowledged the findings, and 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 and preferences, provided clear direction to staff, and/or were implemented for 2 of 3 residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the community in 01/2021 with diagnoses including Alzheimer’s disease and was identified in the acuity interview as having a history of falls.

The resident’s service plan, dated 05/08/25, and intermediate service plans, dated 03/13/25 to 06/09/25, were reviewed, observations of the resident were made, and interviews with the resident and staff were conducted. The service plan was not reflective of Resident 1’s needs and preferences, lacked clear direction to staff, and/or was not implemented in the following areas:

* Side rails for mobility;
* Fall interventions;
* Hospice services;
* Use of wheelchair;
* Hospital bed;
* Ability to use call light;
* Meal assistance, including provide one item at a time;
* Communication status/needs/assistance;
* Assistance with glasses;
* Pain, including non-pharmaceutical interventions;
* Environmental factors impacting resident’s well-being, including noise;
* Alcohol use cessation;
* Preferred name;
* Preference for open door; and
* Daytime and nighttime sleeping and eating routines.

The need to ensure the implementation of services and that the service plan was reflective of the resident’s needs and preferences and provided clear direction to staff was discussed with Staff 1 (ED) at 10:40 am on 06/11/25. She acknowledged the findings, and no further information was provided.

2. Resident 3 was admitted to the facility in 10/2022 with diagnoses including glaucoma, hypertension, pain from compression fracture mid-back, and dementia. S/he was subsequently admitted to hospice on 04/11/25.

Observations were made of the resident's care on 06/10/25 and 06/11/25, interviews with the resident and facility staff were conducted, and the care plan, dated 04/14/25, was reviewed.

Resident 3's care plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Instructions for aspiration precautions and interventions while choking;
* How side rails were to be used and monitored for safety;
* Instructions on specific changes of condition to report to hospice;
* Physician Orders for Life Sustaining Treatment status;
* Number of staff needed to assist with activities of daily living;
* Number of staff needed to assist with grooming and eating;
* History of dehydration;
* Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort;
* Instructions on to whom to report skin impairments;
* Personality, including how the person copes with change or challenging situations;
* Number of staff needed to assist with emergency evacuations;
* Instructions on peri and skin care;
* Use of barrier cream with toileting changes; and
* How a person expresses memory loss.

The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (AED), and Staff 3 (Health Services Director/RN) on 06/11/25 at 12:45 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document weekly progress until the condition resolved for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 10/2022 with diagnoses including glaucoma, hypertension, pain from compression fracture mid-back, and dementia. S/he was subsequently admitted to hospice on 04/11/25.

Resident 3's observation notes, dated 03/17/25 through 04/23/25, care plan, dated 04/14/25, additional intermediate service plans, and after-visit summaries from the off-site providers were reviewed.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

* 04/05/25: “…there are open sores now on residents [sic] coccyx that are bleeding…”;
* 04/08/25: “…seems like there is a pressure sore on [his/her] right heal [sic].”;
* 04/11/25: admitted to hospice and all previously scheduled medications were discontinued;
* 04/23/25: “…has breakdown in buttocks right side…”; and
* 05/14/25: “…took 1st dose of morphine (for pain)...watch for effectiveness …”

The need to ensure the facility had a system to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, to communicate the determined action or intervention to staff, and to document progress until the condition resolved was reviewed with Staff 1 (ED), Staff 2 (AED), and Staff 3 (Health Services Director/RN) on 06/11/25 at 12:45 pm. They acknowledged the findings.

2. Resident 1 moved into the community in 01/2021 with diagnoses including Alzheimer’s disease and was identified in the acuity interview as having a history of falls.

The resident’s 03/13/25 to 06/09/25 progress notes, incident reports, outside provider notes, and intermediate service plans were reviewed.

a. There was no documented evidence the following short-term changes of condition had actions or interventions determined, documented, and communicated to staff on each shift:

* 04/12/25 – Hospice admit;
* 04/29/25 – “Edema +1 pitting bilaterally”;
* 05/09/25 – Medication change and family no longer bringing alcohol in for the resident;
* 06/03/25 – Unwitnessed fall.

b. There was no documented evidence the following short-term changes of condition had monitoring with weekly progress noted to resolution:

* 04/29/25 – “Edema +1 pitting bilaterally”;
* 05/28/25 – Bruise on “lower back left side”; and
* 06/03/25 – Left knee abrasion.

The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift, with weekly progress noted to resolution for all short-term changes of condition was discussed with Staff 1 (ED) at 10:40 am on 06/11/25. She acknowledged the findings, and no further information was provided.

3. Resident 2 was admitted to the facility in 06/2023 with diagnoses including schizoaffective disorder and bipolar disorder.

Resident 2’s progress notes, dated 03/25/25 through 05/21/25, service plan dated 04/02/25, and intermediate service plans were reviewed.

The resident experienced multiple short-term changes without documented monitoring of progress at least weekly until resolution and/or lacked resident-specific directions to staff in the following areas:

* 03/25/25 – Fall;
* 04/01/25 – Abscess in left armpit and new medication;
* 04/03/25 - Positive for MRSA; and
* 04/24/25 – New medication.

During an interview with Staff 1 (ED) on 06/11/25 at 1:30 pm, she acknowledged the lack of monitoring of progress for changes of condition through resolution and the lack of actions or interventions determined and communicated to staff.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 on 06/11/25. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included resident-specific parameters and instructions for PRN medications ordered by a legally recognized prescriber and administered by the facility for 2 of 3 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 10/2022 with diagnoses including glaucoma, hypertension, pain from compression fracture mid-back, and dementia. S/he was subsequently admitted to hospice on 04/11/25.

Resident 3's MAR from 05/01/25 through 06/11/25 and physician orders were reviewed and revealed the following:

a. The following PRN medications lacked instructions for sequential order of use:

* Acetaminophen 500mg (for pain or fever);
* Acetaminophen 650mg suppository (for pain or fever);
* Diclofenac Sodium 1% gel (for pain); and
* Morphine Sulfate 20mg/ml (for pain).

b. The following PRN medications lacked resident-specific parameters for use:

* Haloperidol 2mg/ml (for anxiety, agitation, or hallucinations); and
* Lorazepam 0.5mg (for anxiety or agitation).

c. The following medications lacked clear, specific instructions:

* Bisacodyl 10mg suppository (for bowel care);
* Milk of Magnesia 400mg/5ml (for bowel care);
* Miralax Powder (for bowel care); and
* Fleet enema (for bowel care).

The need to ensure MARs were accurate and provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (ED), Staff 2 (AED), and Staff 3 (Health Services Director/RN) on 06/11/25 at 12:45 pm. They acknowledged the findings.

2. Resident 1 moved into the community in 01/2021 with diagnoses including Alzheimer’s disease.

The resident’s 05/01/25 to 06/09/25 MAR and current physician orders were reviewed. The resident had signed orders for the following:

* Acetaminophen 500 mg caplet, as needed for pain;
* Acetaminophen, 650 mg suppository as needed for pain; and
* Morphine sulfate 20 mg/ml solution, 0.25 ml by mouth every hour as needed for pain.

Review of the MAR indicated staff administered the acetaminophen caplet on 05/27/25, and the morphine on seven occasions between 05/27/25 and 06/03/25. There were no resident-specific parameters to direct unlicensed staff on the sequential order of administration.

In an interview at 10:36 am on 06/10/25, Staff 7 (MA) reviewed the resident’s MAR and confirmed the three PRN pain medications lacked instructions for staff.

The need to ensure resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (ED) at 10:40 am on 06/11/25. She acknowledged the findings, and no further information was provided.

Based on observation, interview, and record review, it was determined the facility’s Acuity-Based Staffing Tool (ABST) did not accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to:

A review of ABST documentation, interviews, and observations throughout the survey were completed. The following was identified:

* The minutes recorded on the ABST did not match services provided by staff in multiple areas for Residents 1 and 2.

The need for the ABST to accurately capture care time and care elements that staff were providing to each resident was discussed with Staff 1 (ED) on 06/11/25. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Facility fire drills records from 12/2024 to 06/2025 were reviewed.

a. The records lacked documented evidence of completing fire drills on alternating months from fire and life safety training.

b. Fire drills completed lacked the following documentation:

* Time of fire drill;
* Problems encountered, comments related to residents who resisted or failed to participate;
* Evacuation time period needed; and
* Number of occupants evacuated.

The need to ensure fire drills were conducted in accordance with OFC was discussed with Staff 1 (ED) at 10:40 am on 06/11/25. She acknowledged the findings, and no further information was provided.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 10/18/2022. 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review it was confirmed that the facility failed to have an Acuity Based Staffing Tool that accurately reflected the resident population and their needs. Findings include the following:During an unannounced site visit on 10/18/2022 Compliance Specialist (CS) reviewed the facilities Acuity Based Staffing Tool (ABST) against the facilities resident roster it was discovered that some of the residents listed on the ABST did not have any time included on their ABST for any need. CS reviewed the most recent service plan for Resident #2 (R2) and Resident # 3(R3) against the facility ABST for R2 and R3 and inconsistencies were identified between R2s' and R3s' service plans and their ABST questions. Service plan indicated that R2 and R3 have the need for assistance with personal hygiene and grooming but the ABST indicates that no time is used for these activities. In an interview with Staff #1 (S1) on 10/18/2022 who stated that the facility has not updated the ABST in over a month and some of the residents that have moved in since then have not been added to the ABST.

The findings of the re-licensure survey, conducted 04/25/22 through 04/27/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 04/27/22, conducted 01/23/23 through 01/24/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the re-licensure survey, conducted 04/25/22 through 04/27/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.Refer to deficiencies in report.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:During the survey, conducted 04/25/22 through 04/27/22, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.Refer to the deficiencies in the report.

Based on observation, interview and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#1) was treated with respect and dignity. Findings include, but are not limited to:Resident 1 was admitted to the facility in 10/2019 with diagnoses including vascular dementia. A review of the current service plan, temporary care plans, incident reports and interviews with staff were conducted during the survey. On 04/26/22 at 11:08 am, the resident's door was open to the hallway. The resident was observed lying in bed, which was positioned next to a large window with the blinds open. The resident was not wearing a shirt or pants. The resident had on an incontinence brief and a thin white blanket partially covered the brief. The remainder of the resident's body was exposed. The resident had garbled speech and difficulty stating his/her preference for not wearing any clothing. The surveyor used the resident's call pendant to alert staff. Staff 8 arrived seven minutes later to assist the resident to get up and put clothes on. A review of the service plan dated 01/19/22 indicated the resident required assistance with dressing. The above observation was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Services Director) on 04/26/22. Staff 1, 2 and 3 were unable to confirm if this was the resident's preference, however acknowledged the window blinds needed to be closed for privacy. On 04/27/22 at 9:30 am, the resident's door was open to the hallway. The resident was observed lying in bed with the blinds open. The resident was not wearing a shirt or pants. The resident had on an incontinent brief and a thin white blanket partially covered his/her body. Staff 3 alerted Staff 1 and 2, who immediately entered the resident's apartment, closed the door and assisted the resident with dressing for the day. The facility failed to ensure the resident received services in a manner that preserved privacy, dignity and respect.The above findings were discussed with Staff 1, Staff 2 and Staff 3 on 04/27/22 at 10:05 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to thoroughly investigate incidents of unwitnessed injury falls to reasonably conclude the incident was not the result of suspected abuse or neglect and failed to report to the local SPD office for 1 of 1 sampled resident (#1) who had unwitnessed injury falls. Findings include, but are not limited to:During the entrance interview on 04/25/22, Resident 1 was identified with multiple injury falls. Resident 1 was admitted to the facility in 10/2019 with diagnoses including vascular dementia and had a history of falls. The following fall interventions were documented in the resident's 01/19/22 service plan:* Keep pathways clear; * Reminders to use front wheel walker;* Regular medication review to prevent falls;* Two hour safety checks during night shift; and* Complete quarterly fall assessment. A review of progress notes and incident reports identified the following:Resident 1 had experienced seven unwitnessed injury falls from 01/13/22 through 04/21/22.The facility failed to conduct immediate investigations which reasonably concluded the falls with injuries were not the result of abuse/neglect. The need to ensure all incidents were thoroughly investigated and reported to the local SPD office if abuse or neglect could not be reasonably ruled out was discussed with Staff 1 (ED), Staff 3 (Assistant ED) Staff 3 (Health Services Director) on 04/26/27. They acknowledged the findings.The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 04/27/22 prior to survey exit.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 04/25/22 at 9:45 am, the kitchen was toured and observed to need cleaning and repairs in the following areas:a. Food spills, splatters, debris, dust and black matter was observed on or underneath the following:* Interior of cupboards and cabinets, including dust and debris on pipes;* Inside doors and bottom floors of refrigerators and freezers;* A fan on the floor by the dry food storage room;* Baseboards and walls;* The metal transition strip on the floor at the back door that led outside; * Cobwebs on the wall by the back door;* The oven grills, burners and inside the oven;* Floor surfaces beneath the dish machine, ice machine and steam table; and * Ceiling vents.b. The following areas needed repair:* Wooden door frame panels had chips, cracks and gouges with exposed wood; and * There was a pink plastic wash basin and a metal container on the floor beneath the ware washer. Discolored, pooled water was visible on the floor underneath the basin and metal container.c. Additional observation:* The back door leading outside was propped open, posing a risk of poor prevention of insects and rodents entering the kitchen area. Staff closed the door upon request.The need to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed and the kitchen was toured with Staff 1 (ED) on 04/25/22 at 10:30 am. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations were completed and addressed all required elements prior to the move in for 1 of 1 sampled resident (#3) whose record was reviewed. Findings include, but are not limited to:Resident 3 was admitted to the facility in March 2022. Resident 3's records were reviewed on 04/25/22.There was no documented evidence that a move-in evaluation was completed and addressed all required elements prior to the move-in date. The need to ensure move-in evaluations were completed and addressed all required elements prior to move-in was discussed with Staff 1 (ED) and Staff 3 (Health Services Director) 04/25/22 at 1:30 pm. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were completed, reflective of resident needs and provided clear direction to staff regarding the delivery of services for 2 of 4 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 03/2022 with diagnoses of Atrial fibrillation and risk of falls. Resident 3's records were reviewed on 04/25/22.There was no documented evidence an initial service plan, reflective of the resident's needs and providing clear direction to staff on delivery of services, was completed. The need to ensure resident service plans, reflective of resident needs and providing clear direction to staff regarding delivery of services, were completed was discussed with Staff 1 (ED) and Staff 3 (Health Services Director) 04/25/22 at 1:30 pm. They acknowledged the findings
2. Resident 1 was admitted to the facility in 10/2019 with diagnosis including, vascular dementia, insulin dependent diabetes, and congestive heart failure. Observations of the resident, interviews with staff, review of the service plan dated 01/19/22, and temporary care plans showed the service plan was not reflective of the resident's current care needs, had not been updated when the resident experienced a significant change of condition, and did not provide clear direction to staff in the following areas: * Cognition, including memory, orientation, confusion and decision making ability;* Communication and speech;* Weakness and pain in legs and hip;* Fall interventions, including the use of fall mat;* One-two person transfers;* Mobility, including the use of a manual wheelchair;* Toileting assistance and incontinent care;* Use of an electric hospital bed with bilateral side rails;* Weight bearing status;* Full assistance with dressing and grooming; and* Diabetic nail care.The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and were updated after significant changes of condition was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Services Director) on 04/26/22 at 12:30 pm. They acknowledged the findings.

2. Resident 2 was admitted in 2019 and had a history of falls and skin injuries.Resident 2's clinical record and charting notes, reviewed from 01/01/22 through 04/25/22, revealed the following: a. On 01/13/22 and 01/19/22, the resident sustained skin injuries. Documentation indicated the facility treated the injuries and initiated monitoring. However, the record revealed no documented monitoring of the wounds at least weekly until resolved. b. The resident fell on 02/01/22. Review of the record revealed no documented evidence the facility monitored and documented on the progress of the resident's condition at least weekly until resolved.The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed on 04/27/22 with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure residents who had a significant change of condition were evaluated, referred to the RN for an assessment and the service plan updated as needed for 1 of 1 sampled resident (#1), failed to monitor and document weekly progress of short-term changes of condition until the conditions resolved, and monitor the effectiveness of interventions developed for 1 of 3 sampled residents (#2). Resident 1 experienced an overall health decline and multiple falls with injuries which lacked monitoring of fall interventions for effectiveness and referral to the RN when appropriate. Resident 1 continued to decline in health status and injury falls. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 10/2019 with diagnoses including vascular dementia and had a history of falls. Resident 1's progress notes, dated 01/13/22 through 04/26/22, service plan dated 01/19/22, with hand-written updates on 02/04/22, 02/09/22 and 03/03/22, additional temporary care plans, significant change of condition evaluation dated 04/08/22 and incident reports were reviewed. a. The following fall interventions were documented in the resident's 01/19/22 service plan:* Keep pathways clear; * Reminders to use front wheel walker;* Regular medication review to prevent falls;* Two hour safety checks during night shift; and* Complete quarterly fall assessment. Between 01/13/22 and 04/26/22 the resident experienced the following falls with injuries: * On 01/21/22, Resident 1 was "on alert for fall and injuries [fall on 01/13/22], wound on nose is scabbed. Forehead wound cleansed and covered";* On 03/29/22 at 3:45 am, Resident 1 was found on floor in apartment with bruising to right elbow and left side of back;* On 04/05/22 at 3:40 am, Resident 1 was found on the floor with bruising to the head/forehead;* On 04/07/22 Resident 1 had an injury fall in apartment doorway at 4:00 am with laceration on back of head, resident sent to hospital;* On 04/14/22 at 1:45 am the resident was found on floor in apartment. Resident had skin tears on left arm by the elbow and forearm. Resident was lethargic after the fall. Resident stated s/he hit his/her head and paramedics transferred the resident to the hospital. Resident 1 returned to the facility on 04/18/22 at 1:32 pm.* On 04/18/22 at 2:00 pm, the resident had a non-injury fall. * On 04/21/22 at 4:00 pm, the resident had a fall and hit his/her head on metal bed frame. There was no documented evidence the facility reviewed and monitored fall interventions for effectiveness, developed and implemented new fall interventions for any of the falls that occurred between 01/13/22 and 04/26/22 to prevent further injury falls.During an interview on 04/26/22 with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director), they acknowledged the pattern of falls was a change in the resident's current status. Staff 3 acknowledged the lack of an evaluation for the pattern of falls and the lack of referral to the RN for assessment. There was no documented evidence the facility evaluated the falls in relation to the resident's condition, referred to the RN for assessment and updated the service plan after the significant change of condition. The failure of the facility to evaluate the resident, review previous fall interventions for effectiveness and develop new interventions to prevent future falls placed the resident at risk for continued falls and injuries. The need to ensure the facility had a system in place to evaluate the resident's changes in condition and refer to the RN when appropriate was discussed with Staff 1, Staff 2 and Staff 3 on 04/27/22. They acknowledged the findings. b. Between 01/13/22 and 04/26/22 the resident was hospitalized on five occasions, experienced increased confusion, disorientation, an increase in his/her ADL care needs, and an overall decline in his/her condition. This represented a significant change of condition that required an evaluation and referral to the RN for assessment. There was no documentation that the RN was notified of the resident's changes in condition and health status.During an interview on 04/26/22 with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director), they acknowledged the resident's change of condition was triggered on 03/19/22, however, an evaluation wasn't completed and the RN wasn't notified. Staff 3 indicated she wasn't aware of the resident's change in condition and acknowledged the lack of an evaluation, RN assessment and an update to the service plan.The need to ensure the facility had a system in place to evaluate the resident's changes in condition and refer to the RN when appropriate was discussed with Staff 1, Staff 2 and Staff 3 on 04/27/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN conducted an assessment of the resident's significant change of condition which documented findings, resident status and interventions made as a result of the assessment for 1 of 1 sampled resident (#1). Resident 1 experienced an overall health decline, a pattern of falls with injuries and a hospice admission which lacked an RN assessment. Resident 1 continued to experience injury falls. Findings include, but are not limited to:Resident 1's progress notes, dated 01/13/22 through 04/26/22, service plan dated 01/19/22, with hand-written updates on 02/04/22, 02/09/22 and 03/03/22, additional temporary care plans, significant change of condition evaluation dated 04/08/22 and incident reports were reviewed. a. The following fall interventions were documented in the resident's 01/19/22 service plan:* Keep pathways clear; * Reminders to use front wheel walker;* Regular medication review to prevent falls;* Two hour safety checks during night shift; and* Complete quarterly fall assessment. Between 01/13/22 and 04/26/22 the resident experienced seven falls with injuries. The pattern of falls was a change in the resident's current status and represented a significant change of condition for which an RN assessment was required. There was no documented evidence the facility RN completed an assessment of the resident's significant change of condition with documented findings, resident status and interventions made as a result of the assessment.During an interview on 04/26/22 with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director), they acknowledged the pattern of falls was a change in the resident's current status and required an RN assessment.The failure to ensure the RN conducted an assessment of the resident's significant change of condition with documented findings, resident status and interventions made as a result of the assessment resulted in continued injury falls.The need to ensure the facility RN assessed all significant changes of condition was discussed with Staff 1, Staff 2 and Staff 3 on 04/27/22. They acknowledged the findings. Refer to C 270, Example 1ab. Between 01/13/22 and 04/26/22 the resident was hospitalized on five occasions, experienced increased confusion, disorientation, increase in his/her ADL care needs, an overall decline in his/her condition and was admitted to hospice. This represented a significant change of condition that required an RN assessment which documented findings, resident status and interventions made as a result of the assessment.There was no documentation of an RN assessment which documented findings, resident status and interventions made as a result of the assessment.During an interview on 04/26/22 with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director), they acknowledged the multiple hospitalizations, changes in cognition and ADL care needs and admission to hospice represented a significant change of condition which required an RN assessment.The need to ensure the facility RN assessed all significant changes of condition was discussed with Staff 1, Staff 2 and Staff 3 on 04/27/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. Findings include, but are not limited to:During the relicensure survey, conducted 04/25/22 through 04/27/22, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas:C 302: Systems: Tracking Controlled Substances;C 303: Systems: Medication and Treatment Orders;C 305: Systems: Resident Right to Refuse; C 310: Systems: Medication Administration; and C 325: Systems: Self-Administration of Medication.Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 04/27/22.

Based on observation, interview and record review, it was determined the facility failed to ensure a system was in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#2) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:Resident 2 admitted to the facility in September 2019 with diagnoses of Type 2 Diabetes and hypertension. The resident's record, including the MARs between 03/01/22 and 04/25/22 and the Controlled Substance Disposition logs were reviewed during the survey.* Between 03/01/22 and 04/25/22, there were four instances that the documentation on the MARs and the Controlled Substance Disposition log did not match for administration of oxycodone 5 mg tablets; and * On 03/03/22, 04/04/22, 04/05/22 and 04/07/22, the medication was signed out on the Controlled Substance Disposition log but was not documented as given on the MAR. The need to ensure a system was in place for accurately tracking controlled substances administered by the facility was discussed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 3 (Health Services Director) on 04/27/22 at 10:15 am. They 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 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:1. Resident 2 moved into the facility in 2019 with diagnoses including insulin dependent diabetes. Physician orders and MARs for Resident 2, reviewed from 04/01/22 - 04/25/22, revealed the following orders were not followed:a. Lantus 26 units daily at bedtime was not given on 04/04/22, 04/09/22 and 04/12/22. Additionally, no CBG was documented. Staff circled their initials indicating the insulin was not administered. However, the reason why it was not given was unclear. b. Victoza 1.8 mg (injectable diabetic medication) was not given on 04/09/22 and 04/12/22. Staff circled their initials indicating the medication was not administered. However, the reason why it was not given was unclear.c. Mirtazapine (for depression) 15 mg one tablet at bedtime was not given on 04/08/22. Staff circled their initials indicating the medication was not administered. However, the reason why it was not given was unclear.d. On 04/08/22 and 04/09/22, the following medications were not administered: Pregabalin (relieves neuropathic pain) 150 mg two capsules daily at bedtime, Rogaine Women's one squirt applied to scalp daily, and Ropinirole (treats restless leg syndrome) 2 mg two tablets daily at bedtime. Staff circled their initials indicating the medications were not given. However, the reason why they were not administered was unclear.e. Resident 2 had orders for staff to take monthly vital signs. On 04/01/22, staff circled their initials and indicated the vital signs would be taken "tomorrow". There was no further documentation that the vital signs were obtained.f. Cranberry tablets 200 mg twice daily was not documented as given from 04/18/22 through 04/23/22. g. On 04/04/21, the following medications were not documented as given: Victoza 1.8 mg injection, Pregabalin 150 mg two capsules, Rogaine Women's Foam application to scalp, Ropinirole 2 mg two tablets, Circaids leg wraps for edema, and Vaseline treatment to legs. On 04/26/22 at 2:05 pm, the surveyor and Staff 7 (MT) observed/checked the MARs and medication supply. Staff 7 was unable to verify if the above orders had been followed.The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director) on 04/26/22 and 04/27/22. They acknowledged the findings. No further information was provided.
2. Resident 1 moved into the facility in 10/2019 with diagnoses including insulin dependent diabetes. Hospital discharge orders dated 04/18/22 and the 04/01/22 - 04/26/22 MAR was reviewed and revealed the following order was not followed:a. Humalog U-100 sliding scale insulin, four times daily (meals and bedtime), at varied amounts based on CBG values was not on the MAR from 04/18/22 - 04/25/22.Interview on 04/26/22 with Staff 2 (Assistant ED), who was administering medications on 04/26/22, confirmed the resident was not receiving the sliding scale insulin from 04/18/22 through 04/26/22. Staff 2 indicated the facility changed from Quick MAR to Alis MAR system and the sliding scale had not been transcribed on the Alis MAR. Staff 2 indicated s/he would follow up and confirm the sliding scale orders.On 04/26/22 surveyor and Staff 7 (MT) reviewed the electronic MAR. The sliding scale insulin was added back on the MAR and the resident had received the sliding scale insulin as of 04/26/22. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director) on 04/26/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#2) who had documented medication and treatment refusals. Findings include, but are not limited to:Resident 2's MARs were reviewed for the time period of 04/01/22 through 04/25/22. Staff documented Resident 2 refused:* Rogaine Women's Hair Foam (for hair growth) on one occasion;* Circaids leg wraps (to control edema) on one occasion;* Vaseline treatment to legs on one occasion; and * Lidocaine patch (for pain) on five occasions. There was no documented evidence the facility notified Resident 2's physician of the refusals.In an interview on 04/27/22, Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director) acknowledged there was no documented evidence the facility had notified the physician of the refusals. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included specific instructions for PRN medications for 1 of 2 sampled residents (#2) whose medications were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 2019 with diagnoses which included insulin dependent diabetes.Residents 2's MARs were reviewed from 04/01/22 through 04/25/22 and the following was noted:a. Resident 2 had orders for Novolog sliding scale insulin four times a day (meals and bedtime) to be given in varied amounts based on CBG results. On 04/18/22, the facility switched from a Quick MAR system to an Alis MAR system. The sliding scale was noted on the Quick MAR from 04/01/22 - 04/17/22. However, it was never transcribed onto the new MAR, and there was no documentation that the resident received additional insulin from 04/18/22 - 04/25/22.In an interview on 04/27/22, Staff 6 (MT) confirmed the sliding scale order was not noted on the current MAR. He added that the insulin was administered, but not documented.b. In an interview with the resident on 04/26/22, s/he stated s/he was on Novolog sliding scale insulin, Aspart insulin, Lantus insulin and Victoza injectable diabetic medication. S/he said staff checked his/her CBGs and drew up the insulin and Victoza, but s/he administered it. The MARs did not indicate that the resident self-administered his/her insulin and Victoza. During interviews on 04/26/22 and 04/27/22 with Staff 3 (Health Services Director), Staff 6 (MT) and Staff 7 (MT), they confirmed staff checked the resident's CBGs and drew up the insulin and Victoza, but the resident administered it. Staff 3 reviewed the MAR and acknowledged it was inaccurate. c. According to the MAR, staff failed to administer the resident's Mirtazapine (for depression) 15 mg one tablet daily on 04/04/22. On 04/26/22 at 2:05 pm, the surveyor and Staff 7 (MT) observed/checked the MARs and medication supply. Staff 6 verified that the medication had been given, but staff failed to document. d. S/he had an order for Diclofenac gel to be applied to "affected area 3 times daily as needed for moderate pain." The MAR lacked resident-specific instructions for the application of the gel. e. The resident had an order for Carbamide ear solution (to treat ear wax). Staff were instructed to administer 1-5 drops into both ears twice daily PRN. The MAR lacked specific parameters indicating circumstances that warranted how many drops were to be given. The need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director) on 04/26/22 and 04/27/22. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to evaluate the resident's ability to safely self-administer medication/treatment upon move-in and at least quarterly and obtained a physician or other legally recognized practitioner's written order of approval for self-administration of medication for 2 of 2 sampled residents (#s 2 and 3) who self-administered medications or treatments. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 2019 with diagnoses which included Type 2 Diabetes. During an Interview on 04/25/22 at 9:30 am, Resident 2 stated that s/he administered his/her own insulin.During an interview on 04/26/22 at 2:30 pm, Staff 7 (MT) reported staff set up the insulin for Resident 2, then the resident injected his/her own insulin.There was no documented evidence the facility evaluated Resident 2's ability to safely self-administer the medication and there was no physician's written order of approval for self-administration of the medication.The need to ensure the facility evaluated the resident's ability to safely self-administer medication upon move-in and at least quarterly, and obtain a physician or other legally recognized practitioner's written order of approval for self-administration of medication was discussed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 3 (Health Services Director) on 04/27/22 at 10:15 am. They acknowledged the findings.2. Resident 3 was admitted to the facility in March 2022.During an interview on 04/25/22 at 1:00 pm, Resident 3 stated that s/he self-administered Warfarin (blood thinner).There was no documented evidence the facility evaluated Resident 3's ability to safely administer his/her own medication, and there was no physician's written order of approval for self-administration of the medication.The need to ensure the facility evaluated the resident's ability to safely self-administer medication upon move-in and at least quarterly, and obtained a physician or other legally recognized practitioner's written order of approval for self-administration of medication was discussed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 3 (Health Services Director) on 04/27/22 at 10:15 am. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed at least quarterly for assistive devices with potentially restraining qualities for 2 of 2 sampled residents (#s 1 and 2) who had supportive devices. Findings include, but are not limited to:1. Resident 2 admitted to the facility in 2019. The resident's service plan dated 01/24/22 indicated use of ¼ side rails on the bed for stability and positioning. During an interview with Resident 2 on 04/26/22 at 9:30 am, side rails were observed in a down position on both sides of the bed. Resident 2 stated s/he used the side rails to help with positioning when s/he was in bed.There was no documented evidence the facility registered nurse, a physical therapist or occupational therapist had conducted an assessment of the use of the ¼ side rails.The need to complete assessments of supportive devices with restraining qualities was discussed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 3 (Health Services Director) on 04/27/22 at 10:15 am. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 10/2019 with diagnosis including vascular dementia.The resident's service plan dated 01/19/22, temporary care plans, observations and interviews with staff were conducted during the survey. During an interview with Resident 1 on 04/26/22 at 11:08 am, 1/4 length bilateral side rails were observed at the head of the bed and in the up position while the resident was lying in bed. Resident 1 had garbled speech with difficulty communicating complete sentences, however Resident 1 repeatedly said "this thing, this thing" while hitting his/her hand against the bed rail. There was no documented evidence the facility RN, PT or OT had conducted an assessment and the facility failed to document the following: * The resident specifically requested or approved of the device and the facility had informed the individual of the risks and benefits associated with the device;* The facility documented other less restrictive alternatives evaluated prior to the use of the device; * The facility instructed caregivers on the correct use and precautions related to use of the device; and* Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and the use of the side rails was documented in the resident's service plan was discussed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 3 (Health Services Director) on 04/26/22 12:30 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia training was completed prior to providing care to residents for 1 of 3 newly hired direct care staff (# 9) whose training records were reviewed. Findings include, but are not limited to:Staff training records were reviewed on 04/26/22. Staff 9 (MT), hired 01/03/22, lacked documented evidence pre-service dementia training was completed prior to performing job duties.The need for staff to complete all required pre-service dementia training before working with residents was reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 04/27/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 9, 10 and 11) completed all required training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 04/26/22. The following deficiencies were identified:1. Staff 9 (MT), hired on 01/03/22 and Staff 10 (MT), hired on 01/22/22, lacked documented evidence of demonstrated competency in all required areas within 30 days of hire including: * Role of service plans in providing individualized care;* Providing assistance with ADL's;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting;* General food safety, serving and sanitation; and* Other duties as applicable (medication administration).2. Staff 9 and 10 lacked documented evidence of having completed First Aid and abdominal thrust training within 30 days of hire.3. Staff 11 (CG), hired on 03/08/22, lacked documented evidence of having demonstrated competency in the following areas:* Providing assistance with ADL's;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting; and* General food safety, serving and sanitation.The need to ensure newly hired direct care staff completed First Aid and abdominal thrust training and demonstrated competency in all required training topics within 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 04/27/22. They acknowledged the lack of training documentation.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire drill and life safety records were reviewed on 04/25/22. The facility failed to evacuate and/or relocate residents during monthly fire drills. Therefore, documentation was incomplete in the following areas:* Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and* Number of occupants evacuated.In an interview on 04/25/22 at 2:54 pm, Staff 5 (Dining Service Director), who was the former Maintenance Director, acknowledged the facility failed to evacuate residents and to complete documentation related to the evacuation of residents. The requirements for conducting fire drills and maintaining completed fire drill records was discussed with Staff 1 (ED) on 04/27/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission, and re-instruct residents at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:On 04/26/22, Staff 1 (ED) was asked to explain the facility's process and provide documentation for instructing residents in fire and life safety procedures upon admission and annually. Staff 1 was unable to provide a clear description of their process for training residents in fire and life safety procedures and was unable to provide any supporting documentation related to the completion of the required training's.The need to instruct residents upon move-in and annually in general fire safety procedures was discussed with Staff 1 on 04/27/22. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways in the ALF's common-use areas were maintained in good repair. Findings include, but are not limited to:The exterior grounds were toured on 04/25/22 at 1:03 pm. There were drop-offs of up to two inches from the pavement to the planting bed at the corners and along the edges of multiple pathways around the perimeter of the building. These drop-offs created potential tripping or fall hazards for residents.On 04/27/22 at 10:45 am, the surveyor showed Staff 1 (ED) and Staff 2 (Assistant ED) the drop-offs. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to keep all interior and exterior surfaces clean and in good repair. Findings include, but are not limited to:The interior and exterior of the building were toured on 04/25/22 at 11:07 am. The following areas needed cleaning or repair:* Wooden door trim surrounding resident rooms 203, 204, 209, 211, 212, 216, 217, 301, 306 and 308 had gouges with exposed bare wood;* The rubber door seal was coming off resident room 306's door;* Carpet at the entry to resident room 215 was starting to fray, creating a potential tripping hazard; * Sections of the hallway handrails near rooms 104,106 and 215 had protruding hardware and/or were not connected, leaving a rough surface;* The area above the fireplace was coated in black residue;* Exit doors in the laundry room and at the end of the 300 hall had black streaks across lower portion of the doors; * Laundry machines had pink and brown buildup around the bleach compartments;* The area behind the dryers was covered in lint and dust;* The area behind the soda machine in laundry room was covered in dust; and * The outside dryer vent was not covered leading to lint buildup on the pavement in the courtyard. The areas needing cleaning and repair were shown to and discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 04/27/22 at 10:45 am. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure soiled clothing and linens were laundered in a washing machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant. Findings include, but are not limited to: During a tour of the community laundry room on 04/25/22 at 11:35 am, it was observed that there were three residential washing machines present. In an interview with Staff 11 (CG) on 04/25/22 at 3:04 pm, she stated that soiled linen was double bagged, brought to the hopper room, rinsed in the hopper sink and then washed with laundry detergent in the residential washing machines. Staff 11 then confirmed that soiled linens were washed without the use of a chemical disinfectant or a 140 degree Fahrenheit hot water rinse. In an interview with Staff 1 (ED) on 04/27/22, she confirmed that the facility did not use a hot water rinse or a chemical disinfectant when laundering soiled linens.The facility's failure to properly launder soiled clothing and linens was reviewed with Staff 1 and Staff 2 (Assistant ED) on 04/27/22. They acknowledged these findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters did not exceed 120 degrees Fahrenheit (F) when they were installed in locations that were subject to incidental contact by residents or with combustible material. Findings include, but are not limited to:The building was toured on 04/25/22 at 1:30 pm. An electric wall heater was observed in room 110. When it was turned on and the temperature of the surface of the metal grill was measured with the surveyor's digital thermometer, the temperature was noted to be 160.3 degrees F. In an interview on 04/25/22 at 2:10 pm, Staff 1 (ED) reported there were nine similar one-bedroom rooms that had electric wall heaters.On 04/27/22, the surveyors visually inspected the wall heaters in each of the nine rooms. Four rooms were not occupied. There were no obstructions that would put residents at risk in four of the other rooms. One resident had his/her bed pushed up against the wall with the wall heater. However, the resident was alert and oriented, understood the risk and stated s/he did not use the wall heater.The wall heaters that exceeded 120 degrees F were discussed with Staff 1 and Staff 2 (Assistant ED) on 04/27/22. They acknowledged the findings.