Willow Creek Assisted Living

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

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 03/19/26, between 10:45 am and 2:00 pm, the facility kitchen was observed, and the following was identified: Throughout all buildings: 1. Sanitation: * PH test strips were not available to monitor sanitizer solution for non-food contact surfaces; * Sponges were being utilized for ware washing; * No fine tip thermometer or alcohol wipes were available; * Care staff did not have a contact barrier between potentially contaminated clothing and food delivery; and * Food is not covered throughout delivery to resident rooms. 2. Cleaning: * Tops of refrigerator / cappuccino machine – dusty. Building B: 1. Sanitation: * Mini Fridge – without thermometer and routine monitoring; * Apples and bananas that had been sliced and were uncovered, without serving utensils for resident access on the service counter where there was high traffic; and * Surveyor observed resident with bare feet enter the kitchen several times, getting ice from the freezer and using the garbage can. Kitchen entry doors were propped open. Care staff reported that the kitchen was available for residents to use at any time of day. Surveyor requested staff dispose of the ice and clean / sanitize the freezer and ice trays. Building C: * See above areas noted throughout the buildings. Building D: 1. Food Storage: * Surveyor found several deli meats, hot dogs, cheese, and lettuce without dates and/or past expiration dates. Food was discarded. 2. Repair: * Light fixture cover – broken. The areas of concern were observed and/or discussed with Staff 1 (PIC/Dietary Manager) and Staff 2 (Interim Administrator) at approximately 2:00 pm on 03/19/26. Staff acknowledged the findings.

OAR 333-150-000 Sanitation Dietary Manager purchased test strips and they are placed next to the chemical dispensers where the bottles are filled. The proper chemical was purchased and is now inventoried along with the other chemical supply system. When the assigned dietary staff fills/re-fills the bottles, they will be tested before delivering to the individual houses for use. Quality checks will be done at least monthly and upon filling the santizer bottles by the dietary department. Sponges will not be purchased by the community at any time. Health and Dietary staff will be in-serviced that sponges should never be used in our setting. Dietary Manager purchased fine tip thermometers and alcohol wipes. Policy/Process will be established. Health and Dietary staff will be in-serviced on proper. Quality checks will be performed at least monthly by Dietary Manager, or their designee. Dietary Manager will purchased additional aprons for inventory. Health Services employees will be re-educated again on usage of aprons by while servicing food. Quality checks will be completed by Administrators/Resident Care Coordinators weekly to assure proper usage. Plate covers were ordered to provide enough for all houses to be used for any apartment tray deliveries. Staff will be in-serviced. Routine quality checks will be completed by Administrators and/or Dietary Manager or their designees at least weekly for the first month and monthly thereafter. Residents will be notified that the kitchens will need to be secure and foot traffic and access is limited to employees using proper sanitation knowledge. Dietary/Maintenance Director will facilitate the installation of new swinging doors for access to the kitchen. (The other houses have them.) Health and Dietary Services will be in-serviced that the swinging doors should be secured at all times with the exception of when meal delivery is occurring. A posting will be near each door indicated that doors should remain closed. Building B - The mini-fridge has been permanently reomoved. Health Services employees will be re-educated by that all food items mush be in full tact and covered at all times when readily available for residents at the kitchen countertops. See above for reference to entry doors in to the satellite kitchens. Health and Dietary staff will be re-educated reminding them proper dating techniques and guidelines for dating ALL foods. Dietary staff designee will quality check at least weekly for proper implementation and discard any expired foods. Building D - New light fixtures will be ordered, as replacement light covers are no longer available. They will be installed within one week of arrival.

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 411-054-0030 (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, record review, and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchens, food storage areas, food preparation, and food service on 01/06/25 revealed: * Splatters, spills, drips, and debris noted on: - Walls on food preparation areas; - The interior of the ovens; - Shelving throughout kitchen; - Exterior of cupboards and drawers; - Interior of reach in refrigerators; - Interior of drawers, cupboards, and cabinets; and - The drawer, cupboard, and cabinet handles and surfaces where sticky to the touch. * Raw eggs were stored above other foods in the reach in refrigerator. * Un-covered plates and bowls of food were left stored in the microwave in Buildings B and D. * Packaged foods were not dated when opened. * Foods removed from their original packaging for service were not dated and not disposed of after seven days. * Butter, a potentially hazardous food, was stored in the cupboard. * Damage to exterior of drawers and cupboards created un-cleanable surface. * The laminate counter on the right side of the stove in Building D was cracked creating and uncleanable surface. * The garbage in Building D had no lid. * There was no documented evidence of staff consistently monitoring the temperatures of food prepared in the kitchen, refrigerators, and the high temperature dish sanitizer. * There were not small probe thermometers available for staff use in Buildings C and D. * The dish sanitizers in Buildings C and D were not operation. Staff were washing dishes by hand. The dishes were not sanitized. The need to ensure dishes were sanitized was discussed with Staff 3 (Dietary manager) He acknowledged the findings and reported the dishes would be transported to another building to be sanitized until the dish machines in Buildings C and D were operational. The areas in need of cleaning and repair, food storage requirements, and the need to monitor and document temperatures, were reviewed with Staff 1 (Campus Executive Director), Staff 2 (LPN Administrator Designee), and Staff 3 (Dietary Manager) on 01/06/25. They acknowledged the findings.

1.Conduct a deep cleaning of all affected surfaces, including walls, ovens, shelving, cupboards, drawers, refrigerator interiors, and handles. All food will be checked for dates, temp logs will be monitored daily to ensure that temps are being recorded. Reorganize refrigerator storage to ensure raw eggs and other potentially hazardous foods are stored on the lowest shelf in proper containers. Discard all improperly dated or unlabeled foods. Move all potentially hazardous foods, including butter, to appropriate refrigeration. Replace or repair damaged areas to create cleanable surfaces. Temporarily seal cracks to prevent contamination until repairs are completed. 2Assign cleaning tasks to designated staff and verify completion. Post-cleaning, supervisors will inspect all areas to ensure cleanliness. Review and reinforce food labeling policies. Train staff on food storage protocols, emphasizing covered and labeled storage. Schedule quarterly facility inspections to identify and address maintenance concerns 3. Audits will be conducted by the Administrator or designee weekly for 4 weeks, bi-weekly for 2 months and monthly for 1 month. All findings will be reviewed and corrected. 4. Administrator/Dietary Manager

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 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

Based on record review and interview, it was determined the facility failed to ensure 10 of 19 staff reviewed who prepare and serve food had active food handler's certificates (#s 4 thru 13). Findings include, but are not limited to: On 01/06/25 at approximately 10:30 am, the surveyor reviewed employee records for active food handler's cards. There were 10 employees who did not have a food handler's card on file. Staff 1 (Campus Executive Director) acknowledged there were multiple staff that did not have active food handler's certification. Staff 1 verified the staff duties did include preparing and serving food to residents.

1.Completed an audit of all new employee files to ensure that all trainings have been completed with current staff. All trainings were assigned to staff members and completed by 3/7/2025. 2. Developed a new tracking system that will be implementated with all new hires. Each new hires will spend 1 day of training with scheduler/designee and go over all trainings prior to first scheduled shift. 3. This will be reviewed by the Administrator when review of the schedule is compeleted prior to first shift. 4. Scheduler/Administrator

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were updated and modified as needed during the 30 days following the resident's move into the facility for 1 of 1 sampled resident (#4) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome. The resident's Functional Evaluation, dated 08/04/23, and Clinical Comprehensive Assessment, dated 08/04/23, were reviewed. a. The following elements were not addressed in Resident 4's initial move-in evaluation: * Customary routines related to eating; * Personality, including how the person copes with change or challenging situations; * Assistive devices used for eating; * Transportation; * Non-pharmaceutical interventions for pain and how a person expresses pain or discomfort; * Nutrition habits, fluid preferences and weight if indicated; * Complex medication regimen; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature. b. The facility lacked documented evidence the resident's Functional Evaluation and Clinical Comprehensive assessment, both dated 08/04/23, were updated and modified as needed during the 30 days following admission to the facility. The need to ensure move-in evaluations addressed all required elements and were updated and modified as needed during the 30 days following the resident's move into the facility was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Resident #4 will have a new move-in evaluation completed to ensure it includes all required components. 2. Evaluation tool will be modified to ensure it includes all required components. 3. Random audits of move-in and 30-day evaluations will be conducted monthly by the administrator or desginee to ensure continued compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the current resident status as identified in the evaluation, were updated following a significant change of condition, and provided clear direction to staff regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2014 with diagnoses including hypertension, depression, and osteoporosis. Review of Resident 1's most recent service plan, dated 09/25/23, revealed several areas where information differed from the quarterly evaluation, dated 08/31/23. The contradictory findings included the following: *The quarterly evaluation indicated the resident used no side rails or other devices with restraining qualities. The service plan documented the resident used quarter length side rails bilaterally on the bed. Observations were made of the side rails in Resident 1's apartment; and   *The evaluation indicated the resident had experienced no confusion or memory loss, and was alert and oriented x 4 (person, place, time, situation). The service plan indicated Resident 1 had displayed deficits in judgement, and required safety checks every hour at night. On 10/20/23, the need to ensure service plans were reflective of residents' needs and preferences as identified in their evaluations, was discussed with Staff  1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant). They acknowledged the finding 2. Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome and cellulitis of left upper limb. The resident's service plan dated 10/17/23 was reviewed, and observations and interviews with staff and Resident 4 were completed during the survey. The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas: * Upper and lower extremity ulcers; * Toileting assistance required with hygiene and pant management; * Ambulation status; * Prosthesis and related equipment status following recent amputation; * Reading glasses; * Preferences around dining in apartment; * Behaviors toward other residents; and * HH PT and RN services, including who provided services, frequency of visits, and the role of the caregiver and med tech when issues with bandages or changes to ulcerations occurred. b. The facility lacked documented evidence the resident's service plan was reviewed and updated following a significant change of condition related to  stage two upper extremity blisters identified on 09/15/23. The need to ensure service plans were reflective of residents' current needs, included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and was reviewed and updated as needed following a significant change was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Residents #1 & 4 will have new evaluation completed and service plans reviewed and updated to ensure accuracy.   2. Evaluation tool will be updated to prompt updates to the service plan.  Facility leadership team will be educated on the completion of person-centered service plans. 3. Random audits of service plans will be conducted by the administrator or designee quarterly to ensure continued compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure short-term changes of condition had actions or interventions determined and were monitored until resolution for 3 of 3 sampled residents (#s 1, 3, and 4) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 05/2023, with diagnoses including heart disease and chronic pain. The resident's service plan, dated 09/25/23, progress notes, dated 07/09/23 through 10/17/23, skin assessment notes, and interim service plans were reviewed. A progress note dated 08/05/23 documented "resident has open wounds on the front of both legs, cleaned the area and applied a bandage. Notified RN" There was no documented evidence actions or interventions had been determined or the wounds had been monitored until resolution. The need to ensure actions or interventions for short-term changes of condition were documented and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 09/2014, with diagnoses including hypertension, depression, and osteoporosis. The resident's service plan, dated 09/25/23, progress notes, dated 07/09/23 through 10/17/23, skin assessment notes, and interim service plans were reviewed. The progress notes included the following short-term changes: *07/09/23- A caregiver found "blood on [his/her] bottom", and applied cream; and *08/06/23- "Resident has a pea-size open sore next to an already pre-existing sore. Barrier cream was applied". In the four week period between these two identified skin issues there was no documented evidence of monitoring or progress noted, and subsequent documentation confirmed the issues had not resolved. On 10/20/23, the need to ensure short term changes of condition had documentation to reflect monitoring at least weekly, to resolution was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant). They acknowledged the findings. 3. Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome. Observations of the resident and interviews with staff were completed. The resident's service plan, dated 10/17/23, skin assessment notes and progress notes, dated 08/08/23 through 10/17/23, were reviewed. The following was revealed: a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and progress noted, at least weekly, through resolution: * 08/08/23 - Moved to the facility; * 08/09/23 - Pre-move in surgical wound to chest; * 08/09/23 - Lower extremity blisters; * 08/28/23 - Resident complaints of being "drug sick"; * 09/03/23 - Resident concerns of overdosing; * 09/04/23 - Lethargy and "jumbling words together"; and * 09/15/23 - Complications from an off-site CT scan which resulted in blisters to left upper extremity. b. The following short-term change of condition lacked documentation of actions or interventions needed for the resident and the communication of the determined actions or interventions to staff on all shifts: * 09/22/23 - Start of antibiotics. c. The following short-term change of condition lacked documentation of progress noted, at least weekly, through resolution: * 08/22/23 - Fall from wheelchair during self-transfer. The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Residents #1, #3, and #4 will have an interim service plan completed with actions or interventions and wounds will be monitored weekly until resolution.  Actions or interventions will be communicated to staff on all shifts. 2. Residents experiencing a short-term change of condition will be evaluated, actions and interventions identified and communicated to staff through an Interim Service Plan. Residents experiencing a change of condition will have progress documented weekly until resolved. 3. Audits of change of conditions will be conducted weekly by the executive director or designee and results reported to the Quality Assurance Committee.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers and have policies to ensure outside service providers left written information in the facility that addressed the on-site service being provided, for 1 of 2 sampled residents (#1) who received Home Health services. Findings include, but are not limited to: Resident 1 was admitted to the facility in 09/2014 with diagnoses including hypertension, depression, and osteoporosis. During the acuity interview on 10/17/23, Resident 1 was identified as receiving HH nursing services. In another interview on 10/19/23, Staff 3 (LPN) stated all outside provider visit notes were kept in accessible binders in each of the three assisted living buildings on site. The binder for Building D (in which Resident 1 resided) was reviewed. The only recorded HH visit for the resident was an RN note for skin monitoring, performed on the previous day (10/18/23). On 10/19/23, Staff 1 (Administrator) and Staff 4 (Med Aide) stated there was no further outside provider documentation available, including a record of the date HH services where initiated for Resident 1. On 10/20/23 the need to ensure outside service providers left written information in the facility that addressed the on-site services being provided was discussed with Staff 1, Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant). They acknowledged the findings.

1.  Resident #1 is receiving home health services and provider has been educated to provide notes in the facility provider communication binder.   2.  Residents receiving services from an outside provider will have notes left in the facility provider communication binder and will be reviewed by the nurse or designee daily. 3. Audit of outside provider communication will be done by the administrator or designee and results reported to the executive director monthly.

Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment administration system, and failed to ensure adequate professional oversight of the systems. Findings include, but are not limited to: During the re-licensure survey, conducted 10/17/23 through 10/20/23, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C 302: Tracking Controlled Substances; * C 303: Medication and Treatment Orders; * C 305: Resident Right to Refuse; * C 325: Self Administration of Medications; and * C 330: PRN Psychotropic Medications. During the exit meeting on 10/20/23 Staff 1 (Administrator), Staff 2 (Wellness Director), Staff 12 (LPN), Staff 13 (Regional Representative), Staff 14 (RN Consultant) and Staff 15 (Executive Director) were informed the overall medication administration system was determined to be inadequate based on the number of deficiencies related to the above medication areas. They acknowledged the findings.

1.  New facility RN is in place full-time and will be scheduled to take the next Role of the RN course. 2.  All medication technicians will be in-serviced on tracking controlled substances, medication and treatment orders, resident right to refuse, self administration of medications, PRN psychotropic medications and parameters. 3. Audits will be conducted per plans of correction for C302, C303, C305, C325, and C330.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome. The resident's physician orders, the Controlled Substance Disposition logs and the MAR, dated 10/01/23 through 10/17/23 were reviewed. Resident 4 had physician orders for the following controlled medications:   * Alprazolam 0.5 mg - Take one tablet orally in the evening for anti-anxiety; * Alprazolam 0.5 mg - Take one to two tablets by mouth nightly as needed for anxiety or sleep; * Morphine 15 mg - Take three tablets by mouth two times daily for pain; and * Oxycodone 15 mg - Take one tablet by mouth every eight hours as needed for severe pain. The following inaccuracies were identified between the resident's MAR and the Controlled Substance Disposition log: * 10/01/23 - Resident 4's scheduled morphine was documented as administered at 8:00 am and 8:00 pm in the Controlled Substance Disposition log, but it was not documented in the MAR; * 10/02/23 - Resident 4's scheduled morphine was documented as administered at 8:00 am and 8:00 pm in the Controlled Substance Disposition log, but it was not documented in the MAR; * 10/05/23 - Resident 4's PRN alprazolam was documented as administered at 8:00 pm in the Controlled Substance Disposition log, but it was not documented in the MAR; * 10/05/23 - Resident 4's PRN oxycodone was documented as administered at 12:50 pm in the Controlled Substance Disposition log, but it was not documented in the MAR; * 10/13/23 - Resident's 4's PRN oxycodone was documented as administered at 5:31 pm and 11:32 pm in the Controlled Substance Disposition log, but it was not documented in the MAR; and * 10/18/23 - The Controlled Substance Disposition log indicated there were 16 oxycodone pills remaining in the medication bubble pack; however, there were 15 doses remaining. The need to ensure the facility had an effective system for tracking controlled substances was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Resident #4 will have a medication error report completed. 2. Narcotic book and MARs will be reconciled weekly by administrator or designee until ongoing compliance is achieved. 3. Staff will be re-educated on the importance of documentation in the MAR and narcotic book simultaneously and accuracy of the narcotic counts.

Based on observation, interview, and record review, it was determined the facility failed to ensure written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer, and that medication orders were carried out as prescribed for 5 of 5 sampled residents whose orders were reviewed (#s 1, 2, 3, 4, and 5)  Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2023 with diagnoses including heart failure and lower extremity fracture. Resident 2's 10/2023 MAR indicated they administered their own medications. Review of Resident 2's record showed the "medication self-administration safety screen" dated 09/13/23 was incomplete, with no information or safety determination documented. No evaluation of Resident 2's ability to administer their own medications was completed. A progress note dated 10/17/23 stated "Received orders Resident 2 may not self-administer their own medications" In an interview on 10/19/23, Staff 18 (Med Aide) confirmed Resident 2 continued to administer his/her own medications and an observation of the med cart showed no medications stored for Resident 2. The facility had a physician order that Resident 2 was not to self-administer medications, however, interview and record reviewed confirmed Resident 2 continued to keep medications in their room and self-administer. The need to ensure physician's orders were followed was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.   2. Resident 3 was admitted to the facility in 05/2023, with diagnoses including heart disease and chronic pain. Review of Resident 3's 10/2023 MAR and physician's orders showed the following medications were administered without a signed order: * Duloxetine DR 30 mg cap (anti-depressant); * Fluconazole 200 mg tab (anti-fungal); * Spironolcactone 25 mg tab (diuretic); * Potassium CHL ER 200 MEQ (supplement); * Trelegy Ellipta 100-62.5 MCG (steroid inhaler); * Acetaminophen 500 MG 2 tablets (analgesic); and * Albuterol 90 MCG (asthma inhaler). In an interview on 10/19/23, Staff 1 acknowledged there were not physician's orders for the medications the facility was administering. The need to ensure written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer was discussed with Staff 1, Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings, and no additional documentation was provided. On 10/20/23 prior to survey's exit, the facility received signed physician orders from the pharmacy. 3. Resident 5 was admitted to the facility in 10/2022 with diagnoses including Type II Diabetes and hypothyroidism. Review of Resident 5's 10/2023 MAR and current physician's orders showed the following medications were administered without a signed order: * Amlipodine 2.5 mg (blood pressure medication); * Furosemide 40 mg (diuretic); * Insulin Aspart 100 u/ml injection (anti-diabetic); * Jardiance 25 mg (anti-diabetic); * Levothyroxine 112 mcg (thyroid hormone); * Losartan 50 mg (blood pressure); * Trulicity 4.5 mg (anti-diabetic); * Pantoprazole 40 mg (antacid); * Venlafaxine 75 mg (antidepressant); * Eliquis 5mg (blood thinner); * Budesonide 160-4.5mcg (anti-asthma); * Lantus Solostar pen injection (anti-diabetic); * Gabapentin 100 MG (analgesic); * Methocarbamol 750 mg (analgesic); and * Acetaminophen 500 mg (analgesic). In an interview on 10/19/23, Staff 1 acknowledged there were not physician's orders for the medications the facility was administering. The need to ensure written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer was discussed with Staff 1, Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings, and no additional documentation was provided. On 10/20/23 prior to survey's exit, the facility received signed physician orders from the pharmacy. 3. Resident 1's MAR, dated 10/01/23 through 10/17/23, and signed physician orders, dated 10/12/23, were reviewed. The following deficiencies were identified: There were no written, signed orders for the following medications in Resident 1's record: * Aspirin (anticoagulant); * Clobetasol ointment (for irritation); * Clopidogrel (anticoagulant); * Multivitamin tab (supplement); * Nizoral A-D shampoo (for itching); * Pantoprazole (Gastroesophageal Reflux Disease); * Potassium Chloride (venous hypertension); * Amlodipine (hypertension); * Buspirone (for anxiety); * Enalapril Maleate (hypertension); * Gabapentin (for neuropathy); * PRN acetaminophen (for fever or mild pain); * PRN barrier cream (for prevention and healing of skin breakdown); * PRN Bisacodyl supp (constipation); * PRN Bisacodyl tablet (for no BM, by 4th day); * PRN calcium carb (Gastroesophageal Reflux Disease); * PRN clobetasol prop (itchy scaly scalp); * PRN Corn Remover 40% Pads (corn remover); * PRN Ibuprofen (for mild to moderate pain or inflammation); * PRN Ketoconazole 2% shampoo (for dry scalp); * PRN Milk of Magnesia (for no BM, by 3rd day); * PRN PEG 3350 Powder (constipation); and * PRN Preparation H 1% Cream (hemorrhoids). On 10/19/23, Staff 1 (Administrator) acquired signed physician's orders for Resident 1's medications before the survey was completed. On 10/20/23, the need to ensure the facility had written, signed orders in every resident's record for all medications and treatments being administered was discussed with Staff 1, Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant). They acknowledged the findings. 4. Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome. The resident's MAR dated 10/01/23 through 10/16/23 and current physician's orders were reviewed. a. There was no documented evidence of signed physician orders in the resident's facility record for the following medications: * Alprazolam 0.5 mg - Take one tablet orally in the evening for anti-anxiety; * Bactrim DS 800-160 mg - Take one tablet by mouth two times a day for 12 days for cellulitis; and * Spironolactone 50 mg - take one table by mouth daily as a diuretic, hold until patient completes course of Bactrim. On 10/20/23 prior to survey's exit, the facility received signed physician orders from the pharmacy. b. Resident 4 had physician orders for oxycodone 15 mg to be administered every eight hours as needed for severe pain. On 10/11/23, the resident received this medication at 12:02 am, 3:04 am, 7:29 am and 2:44 pm. The medication was given earlier than the prescribed eight hour parameter for all administrations. On 10/19/23 at 2:07 pm, Staff 13 (Regional Representative) confirmed the medication was erroneously set-up in the electronic MAR to allow administration prior to the prescribed parameter. Staff 13 corrected the electronic MAR at that time. The need to ensure physician orders were in the residents' facility record and medication orders were carried out as prescribed was discussed with Staff 1   (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Resident #2's self-administation safety screen has been updated.  Will work with resident, her physician, and caseworker on an agreeable medication administration plan. 2.  Resident #1, #3 and #5's signed orders were obtained and are in the resident charts. 3. Resident #4's PRN order was updated to reflect the accurate order time frame.   4. Signed orders will be reviewed by the administrator or designee and obtained for all other residents. 5.  PRN orders will be reviewed by the administrator or designee and corrected as needed for all other residents. 6. Staff have been educated PRN time frames and administration.   7.  Audits will be conducted of signed orders by the administrator or designee quarterly and findings reported to the Quality Assurance Committee.  PRN orders will be audited by the administrator or designee monthly and findings reported to the executive director.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused consent to an order for 1 of 1 sampled resident (#4) who had documented medication refusals. Findings include, but are not limited to: Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome. The resident's MAR, dated 09/01/23 through 09/30/23, was reviewed and revealed facility staff documented Resident 4 refused the following orders:   * Acetaminophen 325 mg (for pain) on ten occasions. There was no documented evidence the facility notified Resident 4's physician of the refusals. The need to notify the physician/practitioner when a resident refused consent to orders was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Resident #4's physician was notified of resident's refusals of acetamenophen.  Resident's orders will be updated to reflect notification of refusals to physician per physician request. 2. All other residents will be reviewed to ensure direction to staff to notify physician of refusals. 3. Will educate med techs on notification to physician of refusals. 4. Nurse or designee will audit for notification of refusals weekly x 4 then monthly until ongoing compliance achieved.

Based on interview and record review, it was determined the facility failed to ensure residents had a physician's or other legally-recognized practitioner's order of approval for self-administration of prescription medications and were evaluated upon move-in and then at least quarterly to assure ability to safely self-administer medications for 2 of 2 sampled residents (#s 2 and 4) who self-administered their medications. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2023 with diagnoses including heart failure and lower extremity fracture. Resident 2's 10/2023 MAR indicated s/he administered her/his own medications. Review of Resident 2's record showed the "Medication self-administration safety screen" dated 09/13/23 was blank, with no information or safety determination documented. No evaluation of Resident 9's ability to administer their own medications was completed. A progress note dated 10/17/23 stated "Received orders Resident 2 may not self-administer their own medications" In interview on 10/19/23, Staff 18 (Med Tech) confirmed Resident 2 continued to administer her/his own medications and observation of the med cart showed no medications stored for Resident 2. On 10/19/23, the requirement for both a physician's order to self-administer medication, and an RN evaluation of safety before a resident begins to self-administer medications was reviewed with Staff 1 (Administrator). He acknowledged the findings. 2. Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic obstructive pulmonary disease. Resident 4's physician orders and Functional Evaluation, dated 08/04/23, were reviewed and revealed the following: * The resident had an order for albuterol 90 mcg - Inhale two puffs by mouth every six hours as needed for wheezing; and * Staff were to administer all medications for the resident. On 10/19/23 at 11:24 am, Staff 16 (Med Aide) confirmed the facility did not administer the resident's albuterol, rather the resident kept it in his/her apartment and self-administered the medication as needed. A current evaluation of the resident's ability to self-administer prescription medications and a physician order was requested on 10/20/23 at 8:58 am. The facility was unable to provide the requested self-medication evaluation or physician order. The need to ensure residents who chose to self-administer medications were evaluated for safety and had a physician's written order of approval for the self-administration of prescription medications was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Resident #2 and #4's self-administation safety screen will be updated and order obtained as appropriate. 2. All other residents self-administering medications will be reviewed by the nurse or designee to ensure they have been evaluated and there is a physician order for self-administration.   3. Med techs will be in-serviced on resident self-administration of medications. 4. Audits of residents self-administering medications will be conducted quarterly by the nurse or designee.

Based on interview and record review, it was determined the facility failed to ensure medications that were given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (#4) who was prescribed psychotropic medications. Findings include, but are not limited to: Resident 4 was admitted to the facility in 08/2023 with diagnoses including anxiety and insomnia. Review of Resident 4's MAR, dated 10/01/23 through 10/16/23, and physician orders revealed the following: * Resident 4 was prescribed alprazolam 0.5mg - take one to two tablets by mouth nightly as needed for anxiety or sleep; and * Alprazolam was documented as administered to the resident on eight occasions between 10/02/23 and 10/16/23. The facility lacked documented evidence of resident-specific parameters regarding when unlicensed staff were to administer one versus two alprazolam, non-pharmacological interventions were attempted and were ineffective prior to administration of the alprazolam, and the MAR lacked information on which non-pharmacological interventions to attempt. In an interview on 10/19/23, Staff 16 (Med Aide) confirmed the electronic MAR did not have resident-specific parameters or non-pharmacological interventions listed for staff to attempt prior to administering the PRN medication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         The need to ensure medications that treat a resident's behaviors had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 ( Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Resident #4's orders for prn psychotropic medications will be updated to include parameters on when to administer and non-pharmacological interventions that were attempted.   2. All other residents receiving PRN psychotropic medications will be reviewed to ensure paramaters on when to administer and non-pharmacological interventions. 3. Med techs will be in-serviced on parameters and non-pharmacological interventions prior to PRN administration of psychotropic medications. 4. Audits of PRN psychotropic orders will be conducted by nurse or designee monthly.

Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was reviewed before a resident moved into the facility, entries were reflective of the resident's current care needs, and the facility was staffing to the ABST generated staffing level for 2 of 3 residents reviewed (#s 1 and 4) and unsampled residents. Findings include, but are not limited to: 1. A review of the facility's ABST on 10/17/23 and on 10/19/20 with Staff 1 (Administrator) revealed the facility failed to enter all residents prior to move-in and remove residents following discharge from the community.   2. Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic pain syndrome. Observations of Resident 4, interviews with the resident and staff, and review of the resident's records revealed ABST entries were not reflective of the resident's current care needs and had an inaccurate number of minutes assigned in the following areas: * Dressing and undressing; and * Bowel and bladder management. 3. Resident 1 was admitted to the facility in 09/2014, with diagnoses including hypertension, depression and osteoporosis. Observations of Resident 1, interviews with the resident and staff, and review of the resident's records revealed ABST entries were not reflective of the resident's current care needs and had an inaccurate number of minutes assigned in the following areas: * Bowel and bladder management; * Assisting with communication, assistive devices for hearing, vision and speech; * Ambulation, escorting to and from meals and activities; and * Transferring in or out of bed and chair. 4. The facility's posted staffing plan and the ABST generated staffing hours were reviewed with Staff 1 on 10/19/23. It was determined the facility's staffing plan did not consistently meet or exceed the staffing hours generated by the tool. The need to ensure residents were entered into the ABST system prior to moving into the facility, the entries were reflective of the resident's care needs and the facility was staffing to the staff hours generated by the ABST was discussed with Staff 1, Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1.  Resident #1 and #4's Acuity-Based Staffing Tool (ABST) has been updated to reflect the resident's current care needs.   2.  ABST will be updated prior to resident move-in and upon discharge from the community.   3.  ABST generated staffing hours will be reviewed weekly to ensure facility posted staffing plan is accurate and the staffign plan meets or exceed staffing hours generated by the tool. 4. Administrator will be educated on the timeline and monitoring hours in the ABST.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 4, 8 and 9) completed all required pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to: Staff training records were reviewed on 10/18/23 with Staff 17 (Receptionist) and the following were identified: a. Staff 4 (Med Aide), hired on 12/05/22, lacked documented evidence pre-service orientation training was completed in the following areas prior to beginning her job responsibilities: * Resident rights and values of CBC care (completed on 03/07/23); * Abuse reporting requirements (completed on 03/23/23); * Infectious Disease Prevention (completed on 03/08/23); and * Fire safety and emergency procedures (completed on 04/04/23). b. Staff 8 (CG), hired on 07/13/23, lacked documented evidence pre-service orientation training was completed in the following areas prior to beginning her job responsibilities: * Resident rights and values of CBC care (completed on 10/15/23); * Abuse reporting requirements; * Infectious Disease Prevention (completed 10/12/23); and * Fire safety and emergency procedures (completed 10/14/23). c. Staff 9 (CG), hired on 08/21/23, lacked documented evidence pre-service orientation training was completed in the following areas before prior to beginning her job responsibilities: * Resident rights and values of CBC care (completed 10/09/23); * Abuse reporting requirements; * Infectious Disease Prevention (completed 10/10/23); and * Fire safety and emergency procedures (completed 10/12/23). The need to ensure newly hired staff completed all required pre-service training's prior to beginning their job responsibilities was reviewed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1.  Staff #4, #8, and #9 have completed the pre-service orientation trainings.   2.  All newly hired staff will complete all the required pre-service trainings prior to beginning their job responsibilities. 3.  Training records will be reviewed by the administrator or designee for each new hire prior to beginning job responsibilities ongoing.  The executive director or designee will conduct audits quarterly and report results to the Quality Assurance Committee to ensure continued compliance. 4. Administrator and receptionist will be educated on the training requirements.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 4, 8 and 9) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 10/18/23 with Staff 17 (Receptionist) and the following were identified: a. Staff 4 (Med Aide), hired on 12/05/22, lacked documented evidence of competency within 30 days of hire in the following required topics: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting changes of condition (completed on 04/04/23); and * Conditions that require assessment, treatment, observation and reporting. b. Staff 8 (CG), hired 07/13/23, lacked documented evidence of competency within 30 days of hire in the following required topics: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting changes of condition (completed on 10/13/23); and * Conditions that require assessment, treatment, observation and reporting (completed on 10/15/23). c. Staff 9 (CG), hired 08/21/23, lacked documented evidence of competency within 30 days of hire in the following required topics: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting changes of condition (completed on 10/10/23); and * Conditions that require assessment, treatment, observation and reporting (completed on 10/12/23). The need to ensure staff had documented evidence of competency demonstration within 30 days of hire was discussed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Staff #4, #8, and #9 will demonstrate competency of skills in all assigned job duties. 2. Training records will be audited by the administrator or designee every 30 days for compliance. 4. Administrator and receptionist will be educated on the requirement for competency within 30-days of hire.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 1 of 2 long-term staff (#11) whose training records were reviewed. Findings include, but are not limited to: Facility training records were reviewed on 10/18/23 with Staff 17 (Receptionist) and the following was revealed: Training records for Staff 11 (CG), hired 10/03/18, failed to document evidence of 12 hours of required in-service training, including six hours of training related to the care of residents with dementia, between 10/03/22 and 10/03/23. The need to ensure staff completed the required 12 hours of annual in-service training, including six hours of dementia care training was reviewed with Staff 1 (Administrator), Staff 15 (ED), Staff 2 (Wellness Director), Staff 12 (LPN) and Staff 14 (RN Consultant) on 10/20/23. They acknowledged the findings.

1. Staff 11 will complete additional in-servicing to ensure that the requirements are met. 2. All other staff with 1 year or more of service will be reviewed to ensure they meet the annual in-service requirements. 3.  Annual in-service training will be audited by the administrator or designee monthly and findings reported to the executive director. 4. . Administrator and receptionist will be educated on the requirement for annual in-service trainings.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways in good repair, and to ensure all facility grounds were kept orderly and free of refuse. Findings include, but are not limited to: The exterior of the building was toured on 10/17/23. The following issues were noted: * Multiple sections of the concrete path that encircled the building which had drop-offs from the surface of the path to the planting bed of greater than two inches. This represented a fall risk for residents; and * An area observed on the rear grounds which included a mixture of old equipment (medical and exercise), appliances, furniture, tools, and building materials. This area was not kept orderly and presented a potential safety hazard for residents. On 10/19/23 the need to ensure all exterior areas were maintained in good repair was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Director). They acknowledged the findings.

1. Planting beds near the concrete path will have material added to minimize drop-offs. 2. The equipment in the rear grounds of the facility will be cleaned up and old equipment removed. 3. Maintenance director will be educated on the requirement to keep the grounds safe, orderly and free of litter and refuse. 4. Administrator or designee will monitor monthly to ensure ongoing compliance.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to: The facility's interior was toured on 10/17/23 at 1:15 pm. The following issues were identified: Common areas:     * Marks and scrapes on multiple wood doors and frames;     * Patchy paint on walls in D building;     * Dark stains and streaks on hallway carpets throughout facility; and     * Drywall damage and chips on hallway corners in D building. Resident apartments:     Room 8B:     *  Door frame had gouges, scrapes, chipped paint and bare wood exposed;     *  Baseboard was lifting from the wall in multiple places;     *  Laminate flooring was uneven by the closet;     *  Laminate of countertop was chipped with bare wood exposed;     *  Laminate of shelves near refrigerator was chipped with bare wood exposed; and     *  Base of kitchen counter was chipped with bare wood exposed. Room 9C:     * Large white stains visible on bedroom carpet; and     * Water leaking from beneath commode onto bathroom floor. On 10/19/23 the areas in need of cleaning or repair were discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Director). They acknowledged the findings.

1.  Doors and frames will be touched up with paint. 2.  Walls in building D will have the paint updated to minimize the patches. 3.  Carpets have been cleaned. 4.  Drywall damage in hallway corners will be repaired and painted. 5.  Resident apartment 8B will have door frame touched up, baseboard reglued, laminate repaired/patched.  Resident apartment 9C will have bedroom carpet cleaned.  Leak for commode has been repaired. 6. Maintenance director will be educated on maintenance of the interior of the facility.

The findings of the re-licensure survey, conducted 10/17/23 through 10/20/23, 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 Home and Community Based Services Regulations OARs 411 Division 004. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the revisit to the re-licensure survey of 10/20/23, conducted on 02/05/24 through 02/06/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, record review, and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchens, food storage areas, food preparation, and food service on 08/17/23 revealed: * Splatters, spills, drips, and debris noted on: - Shelving throughout kitchen; - Exterior of cupboards and drawers; - Interior of reach in refrigerators; - Lower vents below doors of refrigerators; - Interior of drawers, cupboards, and cabinets; and - The drawer, cupboard, and cabinet handles and surfaces where    sticky to the touch. * Raw eggs were stored above other foods. * Foods were not labeled and dated. * Packaged foods were not dated when opened. * Scoops were left in food bins. * Missing laminate in multiple drawers and cabinets created an un-cleanable surface. * Damage to exterior of drawers and cupboards created un-cleanable surface * There was no documented evidence of staff consistently monitoring the temperatures of food prepared in the kitchen, and the high temperature dish sanitizer. * No documented evidence the sanitizer solution mixed by staff was monitored to ensure correct levels. * Caregiving staff preparing meals and assisting with meal service and delivery were not using aprons. The areas in need of cleaning and repair were reviewed with Staff 1 (Assisted Living Administrator).  He acknowledged the findings.

1. Will clean shelving throughout kitchen, exterior cupboards and drawers, interior of refrigerator, lower vents below door or refrigerator, interior of drawers, cupboards and cabinets. 2. Will obtain and evaluate bids to address the damaged drawers and cupboards and sticky drawer, cupboard, and cabinet handles. 3. All food has been labeled and dated and open dates are present on packaged foods. 4. Missing laminate in drawers and cabinets will be covered/repaired to create a cleanable surface. 5. Staff will utilize temperature logs to document temperatures of food prepared in the kitchen and the high temperature dish sanitizer. 6. Raw eggs were moved so that they are not stored above other foods. 7. Scoops have been removed from food bins. 8. Sanitizer solution will be discontinued and replaced with sanitizing wipes. 9. Staff in the kitchens preparing meals and assisting with meal service will wear aprons.   7. Will in-service all staff on the following: a. Cleaning splatters, spills, drips and debris on kitchen surfaces b. Reporting damage to drawers or cupboards to maintenance c. Labeling and dating food stored in the kitchen d. Temperature logs for prepared food and the high temperature dish sanitizer. e. Safe storage of raw eggs. f. Removing scoops from food bins. g. Use of sanitizing wipes h.  Wearing aprons in the kitchen when preparing meals and assisting with meal service. 8.  Dietary Manager will conduct weekly audits of kitchen cleaning, maintence needs, food labeling and dating, egg storage, temp logs, scoops in bins, use of sanitizing wipes, and aprons and report findings to the Administrator.

Based on observation, record review, and interview, it was determined the facility failed to ensure the facility kitchens were maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the facility kitchens, food storage areas, and cleaning process on 10/11/23 revealed: * Scoops were left in food bins in House B and D. * There was no documented evidence of staff consistently monitoring the temperatures of the high temperature dish sanitizers. The dish machines were not reaching the required temperatures in House B and C. Staff 3 (Executive Director) agreed to have dishes washed in the nursing facility kitchen until the sanitizers were operating per specifications. * There was no sanitizer available for surface cleaning in House B and D. * Refrigerator 1 in House D had a temperature of 50 degrees Fahrenheit on multiple checks. The temperature was documented as 50 degrees Fahrenheit on multiple occasions. The food was moved to a different refrigerator. The above information was reviewed with Staff 1 (Assisted Living Administrator) and Staff 3 on 10/11/23.  They acknowledged the findings.

Scoops have been removed from the food bins and will be replacing with sealed containers for dry storage. Scoops will be on hangers next to containers and not left in containers. Dish sanitizer was repaired in Building B and C and is now at proper cleaning temp 150/180. Forms are updated with what the current temps are to be in the books to record temps of sanitizers each shift.If temps are below the required tempetures staff will notify Maintainance so they can be repaired/adjusted. Kitchen manager will monitor that temps are being recorded Q shift. Kitchen manager and Admin will monitor and coach staff weekly to ensure this is being completed. Cleaning sanitizer have been supplied in each kitchen for cleaning and is stored under the kitchen sinks. Staff will notify Kitchen manager when running low on sanitizer spay so more can be ordered and replaced before running out. This will be checked weekly By Admin to ensure we have in each building. Refridgerator in Building D has been ordered and arrived today. ALF Admin and Kitchen manager will monitor weekly to ensure all corrections are completed and kept in compliance.

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

1. See POC for C240.

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

The findings of the first revisit to the kitchen inspection of 08/17/23, conducted 10/11/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 08/17/23, conducted 01/29/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, record review and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchens, food storage areas, food preparation, and food service on 07/14/22 revealed: * Splatters, spills, drips, and debris noted on: - Cage and blades of fan blowing from window into the kitchen; - Carts used to deliver food; - Shelving throughout kitchen; - Interiors of reach in refrigerators; - Hand-washing sinks; - The blade and casing of can openers; - Microwave interiors; - Interior of the ovens; - The deep fat fryer; - Range tops; and - Interior of drawers, cupboards and cabinets; * Hand-washing sinks were used to hold staff personal items. * There was not a small diameter diameter probe thermometer available  to measure thin foods. * There was no documented evidence of staff monitoring the temperatures of food prepared in the kitchen, and * No evidence of monitoring of the sanitizer levels of the low temperature dish sanitizer. Staff were not able to locate sanitizer strips. The supplier of the dish sanitizer was contacted and strips were provided the same day. * A bag of raw chicken was observed in a container of standing water. Staff 2 immediately began running cold water over the chicken. * Staff were observed to not change gloves between tasks during the preparation of lunch or sanitize hands upon entering the kitchen; and * Caregiving staff assisting with meal service and delivery were not using aprons. The areas in need of cleaning and repair were reviewed with Staff 1 (Administrator) and Staff 2 (Dietary Services Manager).  They acknowledged the findings.

1.Shelving, microwave interiors, oven intereriors, range tops, interior drawers and cupboards cleaned, disinfected and removed grease and sticky areas. Removed splatters, spills, drips and debris. Dish washing racks stored in pantry off of floors on shelf. Door jams repaired allowing staff to clean and disinfect. Laminate replaced in drawers, cabinets and cupboards allowing surfaces to be wiped and disinfected removing splatters, spills, drips and debris. Food temperatures being monitored and recorded by staff for every meal on paper log stored on refridgerator. Raw eggs stored on bottom shelf below other foods. Raw meats being stored on bottom shelf away from ready to eat foods. Trained all staff on proper handwashing techniques and PPE. Will purchase aprons for staff to wear while preparing food. 2. re-training and weekly inspections from administrator to ensure compliance. Maintenance to test dishwasher temps weekly and keep a log. 3. weekly evaluations on staff cleanliness and hand sanitiztion. 4. Emily Garcia, Administrator

The findings of the kitchen inspection, conducted 07/14/22, 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 07/14/22, conducted 10/06/22, 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.