Springs at Tanasbourne

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the re-licensure survey, conducted 07/15/24 through 07/18/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope, severity, and number of citations. Refer to deficiencies in the report.

Refer to C155

Based on interview and record review, it was determined the facility failed to ensure the preparation, completeness, and accuracy of documentation or records for 1 of 3 sampled residents (# 2) whose records were reviewed. Findings include, but are not limited to: During the survey, resident records were reviewed and were found to be missing, inaccurate or incomplete, including signed physicians' orders, onsite provider notes, and temporary service plans. Resident 2 moved into the facility 07/2022 with diagnoses including Parkinson's disease. On 07/15/24 during the acuity interview, Resident 2 was identified as having home health PT, OT and Speech therapy. During an interview with Staff 2 (Health Services Administrator) and Staff 4 (Resident Services Coordinator 3rd floor) on 07/15/24 at 2:45 pm, medical records including signed physician orders, onsite and/or outside provider notes and temporary service plans for Resident 2 were unable to be located. Staff 2 and Staff 4 reviewed the resident's physical chart that was located in the first-floor med room. Staff 2 and 4 reported there was another binder that had the [current] clinical information. The binder in the first-floor med room was for purged documents. They reported that they would find the current binder [medical documents] and get it to the survey team as soon as possible. During an interview with Staff 2 on 07/16/24 at 9:00 am, the surveyor was told the binder had not been found. Staff 2 reported the facility's process was to scan the provider-signed 90 day medication reviews into the electronic record. The surveyor requested the signed orders from the electronic record. During an interview on 07/16/24 at 12:36 pm with Staff 8 (Health Services Quality Coordinator), onsite and/or outside provider notes were requested. No information was received. On 07/16/24 at 12:40 pm, Staff 2 reported she couldn't print Resident 2's physician orders because they were not scanned into the system. Staff 2 stated she could call the physician office and the pharmacy to get a copy of the signed orders. On 07/17/24 at 9:00 am a copy of an onsite provider note from home health PT was provided that indicated the resident was discharged from PT on 03/08/24. No further information regarding onsite services for OT or speech therapy was provided. On 07/18/24 at 11:21 am, survey received a copy of a temporary service plan update that included a summary of previous changes in condition, which included information regarding a change in diet texture and the need for two-person transfers. On 07/18/24 at 11:40 am, survey received a faxed copy of the resident's complete signed physician orders from the prescriber. The orders were dated 01/2024. On 07/18/24 at 3:16 pm the need to ensure facility records were accurate and complete was discussed with Staff 1 (ED), Staff 2, Staff 6 (RN), Staff 7 (Regional RN), Staff 8, Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.

C155 - The chart for Resident 2 has been updated to include all required elements as noted by the survey team, including the physician's order, the outside provider note, and the temporary service plan. Comprehensive review of all charts will be conducted to ensure compliance. Resident Service Coordinators and community nurses will be retrained in appropriate record-keeping practices. RSC will review this quarterly and whenever there are changes in the resident's condition. Health Services Administrator or designee will be responsible for ensuring that the corrections are completed and will provide ongoing oversight.

2. Resident 2 moved into the facility in 07/2022 with diagnoses including Parkinson's disease. The resident's service plan available to staff, dated 05/15/24, and temporary service plan updates were reviewed, and interviews with the resident and staff were conducted. The service plan was not reflective of the resident's needs as identified in the evaluation and lacked clear direction for staff regarding the delivery of services in the following areas: * Evacuation status and level of assistance needed; * Mechanical soft diet verses Regular texture diet; * Mental Health/Anxiety and depression; * Two person assist for toileting and incontinent care; and * Two person transfers with a gait belt. The need to ensure service plans reflected the resident's needs as identified in the evaluation and provided clear direction for staff regarding the delivery of services was discussed on 07/18/24 at 3:16 pm with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding delivery of services for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2022 with diagnoses including Parkinson's disease. The resident's service plan available to staff, dated 03/10/24, and temporary service plan updates were reviewed, and interviews with staff were conducted. The service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Activity assistance; * Weight monitoring; * Mental health history details, including personality; * Bathing; * Dressing; and * Evacuation assistance. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations) on 07/18/24 at 2:20 pm. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 05/2021 with diagnoses including cerebellar ataxia and diabetes. The resident's service plan available to staff, dated 05/27/24, and temporary service plan updates were reviewed, and interviews with staff were conducted. The service plan was not reflective of the resident's needs as identified in the evaluation and lacked clear direction for staff regarding the delivery of services in the following areas: * Expression of wants and needs; * Dressing; * HH PT; * HH mental health; * Wheelchair use as a mobility device; * Transfer assistance; * Mood disorder and interventions; * Medication management; * Activities; * Falls; * Weight and weight changes; * Diabetic insulin status; * Bathing preferences; and * Transportation. The need to ensure service plans were reflective and included clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 4 (Resident Services Coordinator 3rd Floor), and Staff 7 (Regional RN) on 07/18/24 at 2:00 pm. They acknowledged the findings.

C260 - Resident 1 passed away during the survey, so no new changes were made to her chart. The service plans for Residents 2 and 3 have been updated to include all required elements noted by the survey team. Resident Service Coordinators will initiate the individualized service plan with oversight from the Health Services Administrator prior to implementation. RSC will be retrained on ensuring that individualized service plans are in place to provide appropriate care for the residents. The system will be reviewed quarterly or when there are any changes in condition. Health Services Administrator or designee will be responsible for ensuring that the corrections are completed and will provide ongoing oversight.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services, and were reviewed and updated following a significant change of condition for 3 of 4 sampled residents (#s 6, 7, and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 07/2022 with diagnoses including dementia and arthritis. The resident's current service plan dated 09/26/24 was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 12/02/24 and 12/04/24. The service plan had not been updated when the resident experienced a significant change of condition on 11/22/24 when s/he transitioned to hospice. Additionally, the service plan was not reflective and did not provide clear caregiving instruction in the following areas: * Amount of assistance needed with ADLs, including dressing, grooming, mobility, and transfers; * Number of staff to assist with mechanical lift; * Hospice admission; * Responsibility of medication administration; * Preference to eat meals primarily in room; * Use of hospital bed; and * Amount of assistance required for an evacuation. The need to ensure service plans were updated after a significant change of condition was identified, were reflective of current care needs and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 34 (Staffing Coordinator), and Staff 10 (Regional RN) who was present via speaker phone on 12/04/24. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 03/2022 with diagnoses including major depressive disorder, Parkinson's disease and history of falling. Interviews with the resident and facility staff were conducted. The current service plan dated 10/09/24 was reviewed. Resident 6's service plan was not reflective of the resident's current needs and/or lacked clear instructions to staff in the following areas: * Number of staff needed to assist with activities of daily living and emergency evacuations; * Instructions on what types of skin impairments to report and to whom; * Incorrect reference to use of bed cane; * Incorrect reference to use of wheelchair for mobility; * Instructions to staff on whom to report signs and symptoms of complications while on anti-Parkinson and anti-depressant therapy;   * Toileting; * Behavioral problems; * How a person expresses pain or discomfort; and * Personality, including how the person copes with change or challenging situations. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 7 (Regional RN), Staff 33 (Resident Services Coordinator first floor, MC Coordinator), and Staff 10 (Regional RN) who was present via speaker phone on 12/04/24. They acknowledged the findings. 2. Resident 7 was admitted to the facility in 10/2022 with diagnoses including type 2 diabetes. The resident's current service plan dated 11/20/24 was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 12/03/24 and 12/04/24. The service plan was not reflective and did not provide clear caregiving instruction in the following areas: * Outside service providers including names of the home health and private care agencies and the services being provided; * Preference to eat all meals in room; * Use of side rails, including safety checks; and * Skin conditions, including management of lower extremity edema per HHRN instructions. The need to ensure service plans were reflective of current care needs and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 5 (Resident Services Coordinator, second floor), Staff 34 (Staffing Coordinator) and Staff 10 (Regional RN) who was present via speaker phone on 12/04/24. They acknowledged the findings.

1.The service plans for Residents 6, 7, and 8 have been reviewed and updated to include all necessary elements identified by the survey team. For Resident 6 TSPs were located and returned to chart, those that could not be located were recreated and reviewed with care staff, service plan was reviewed and updated. For Resident 7, service plan was reviewed and updated to reflect recommendation for a low sodium diet and leg elavation, TSPs were created and reviewed with staff for these changes. Resident 8 service plan and ABST  were reviewed and updated to reflect admission to hospice. 2. Resident Service Coordinators will initiate the individualized service plans with oversight from Health Services Administrator, RN, or their designee prior to implementation. 3. These service plans will be reviewed quarterly, or sooner if there are any changes in the residents' conditions. 4. Health Services Administrator, RN, or designee will be responsible for ensuring that all required corrections are completed and will provide ongoing oversight.

Based on observation, interview, and record review, it was determined the facility failed to evaluate significant changes of condition and refer to the facility RN, determine actions or interventions needed for short term changes of condition and document weekly progress through resolution for 2 of 3 sampled residents (#s 2 and 3) reviewed with changes of condition.  Resident 3 continued to experience weight loss. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in May 2021 with diagnoses including atherosclerotic heart disease and diabetes. a. During the acuity interview on 07/15/24, Resident 3 was identified as experiencing weight loss. Review of Resident 3's weight records noted the following: *1/12/24: 187 pounds; *02/12/24: 178  pounds.; *03/12/24: 180 pounds.; and *04/12/24: 173 pounds. Between 01/12/24 and 04/12/24, Resident 3 lost 14 pounds or 7.5% body weight in three months resulting in a significant change of condition.  There was no documented evidence the significant change of condition was evaluated and referred to the facility RN including documentation of the change and updating the service plan as needed. Additional weight records noted the following: *05/12/24: 168 pounds; *no weight documented for 06/2024; and *07/17/24: 162 pounds, requested by survey. Between 04/12/24 and 05/12/24 Resident 3 lost an additional five pounds. There was no weight identified in June and at the time of the survey, the resident weighed 162 pounds. During the survey, on 07/17/24 and 07/18/24, the surveyor attempted to watch Resident 3 eat a meal but the resident refused. Resident 3 stated they were independent in eating and took all their meals in their room. In an interview on 07/16/24 at 10:25 am, Staff 17 (CG), stated that Resident 3 had lost a lot of weight and that their clothes no longer fit. Resident 3 experienced significant weight loss between 1/2024 and 04/2024, there was no documented evidence the weight loss was evaluated and referred to the facility RN.  Resident 3 continued to lose weight. The need to ensure the facility evaluated residents with a significant change of condition, referred to the facility RN, documented the change and updated the service plan was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator) and Staff 7 (Regional RN) on 07/18/24 at 2:00 pm. They acknowledged the findings. b. Review of Resident 3's progress notes between 04/16/24 and 07/15/24, identified the following changes of condition: On 04/24/24,  Resident 3 had three medications discontinued: * Ozempic (for diabetes); * Metoprolol (for high blood pressure); and * Allupirinol (to reduce high blood uric acid levels). There was no documented evidence the facility determined and documented what action or intervention was needed for the resident and they did not monitor this short-term change of condition until resolution. The need to ensure the facility evaluated residents with a change of condition, documented the change and monitored until resolution was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator) and Staff 7 (Regional RN) on 07/18/24 at 2:00 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 07/2022 with diagnoses including Parkinson's disease. Clinical records, including the current service plan and evaluation dated 05/15/24, and progress notes from 04/15/24 through 07/15/24 were reviewed and interviews with facility staff and the resident were conducted. a. The facility failed to evaluate, determine action or intervention needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following changes of condition: * 05/19/24 - Urinary tract infection and new antibiotic; and * 06/24/24 - Change in diet orders. b. The resident had the following significant change of condition: * 07/03/25 - Declined mobility - now requiring two person transfer. This constituted a significant change of condition that required referral to the RN. There was no documented evidence the facility evaluated the resident, referred to the facility nurse, documented the change, and update the service plan as needed. The need to ensure the facility had a system to determine and document what actions or interventions were needed for changes of condition, referred to the RN, ensure actions or interventions were communicated to staff on each shift, and ensure progress was documented at least weekly until the conditions resolved was discussed on 07/18/24 at 3:16 pm with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.

C270 - Facility informed the PCP of Resident 3 of weight loss and added a late entry progress note. Weights will be reviewed bi-weekly in acuity meetings with the resident service coordinators, facility nurse, and Health Services Administrator to ensure significant changes are recognized. Resident 2 COC was evaluated by facility RN. The resident care needs have been in review and discussion with family. Service plan is updated to evaluate current and updated care needs. Medtech staff will be retrained on acceptable weight variations and instructed to notify the nurse for follow- up. Health Services Administrator will ensure these bi- weekly acuity meetings occur and will provide printouts of all resident weights for review. Community nurse will initate the COC process within 48 hours of any significant change. Health Services Administrator or designee will be responsible for ensuring that the corrections are completed and will provide ongoing oversight.

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 progress until the condition resolved for 1 of 4 sampled residents (# 6) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: Resident 6 was admitted to the facility in 03/2022 with diagnoses including major depressive disorder, Parkinson's disease and history of falling. Clinical records, including the current service plan and progress notes, from 09/17/24 through 12/01/24, were reviewed, and interviews with facility staff and the resident were conducted. 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: 10/07/24: "Med dose change [anti-Parkinson therapy] and Flu Vaccine"; 10/10/24: unwitnessed fall, blood pressure 189/96 mm/Hg (outside normal parameters); 10/12/24: "caregiver notice multiple bruises on his/her lower back."; 10/13/24: unwitnessed fall; 10/15/24: unwitnessed fall; 10/21/24: "Per OT recommendation resident is to start using weight wrist on right hand with self-feeding ..."; 11/06/24: unwitnessed fall; 11/09/24: " ...Covid Shot"; 11/10/24: "there is also a small open area red in color."; 11/19/24: blood pressure 170/94 mm/Hg (outside normal parameters); The need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 7 (Regional RN), Staff 33 (Resident Services Coordinator first floor, MC Coordinator), and Staff 10 (Regional RN) who was present via speaker phone on 12/04/24. They acknowledged the findings.

1. Community will implement changes to ensure that resident-specific actions and interventions are promptly enacted, communicated to staff, and documented following any short-term change in condition. During a short-term change, a specific, individualized intervention and care plan will be implemented and communicated to staff. 2. RSCs were retrained on short-term and ongoing change of condition needs including; the updating of service plan and ABST, the creation of TSPs, and outside provider notification. 3. During bi-weekly acuity meetings, the Resident Service Coordinator, facility nurse, and Health Services Administrator will review all recommendations from outside providers and ensure that care plans are properly updated. Monthly audits of a random sample of care plans will be conducted to confirm that all external provider recommendations are accurately documented and executed. 4. Health Services Administrator or designee will be responsible for overseeing these updates.

2. Resident 1 was admitted to the facility 04/2022 with diagnoses including Parkinson's disease. During the entrance conference on 07/15/24, Staff 2 (Health Services Administrator) and Staff 4 (Resident Services Coordinator, 3rd Floor) stated the resident had a recent significant decline in health and was recently admitted to hospice services. The resident's clinical record was reviewed and revealed the following significant changes of condition: a. Resident 1 returned to the facility 06/14/24 from a hospitalization followed by a stay at a rehab facility due to a hip fracture. In an interview with Staff 18 (CG) on 07/16/24 at 1:20 pm it was noted upon Resident 1's return from the rehab facility s/he had a significant change in his/her ADLs going from a one person assist to mostly bed bound. The resident's hip fracture constituted a significant change of condition. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. b. On 07/01/24 Resident 1 was admitted to hospice services. The decline in health and admission to hospice constituted a significant change in condition for which an assessment by the facility RN was required. On 07/17/24 at 12:10 pm Staff 7 (Regional RN) stated RN assessments which included documentation of findings, resident status, and interventions made as a result of the assessment had not been completed for the significant changes of condition and no further information was available. The need for an RN to conduct an assessment when a resident experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 2, Staff 6 (RN), Staff 7, Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations) on 07/18/24 at 2:20 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the RN assessed significant changes of condition, documented interventions made as a result of an assessment, the service plan was updated, the licensed nurse participated on the service planning team, or reviewed the service plan with date and signature within 48 hours related to significant change of condition related to residents' significant weight loss, hip fracture and hospice admission for 3 of 3 sampled residents (#1, 2 and 3). Resident 3 experienced continued weight loss. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in May 2021 with diagnoses including atherosclerotic heart disease and diabetes. The resident's 04/16/24 through 07/15/24 progress notes, physician faxes and weight documentation were reviewed. The resident experienced ongoing weight loss as follows:   * 01/12/24: 187 lbs.; * 02/12/24: 178 lbs.; * 03/12/24: 180 lbs.; * 04/12/24: 173 lbs.; * 05/12/24: 168 lbs; and * No weight available for 06/2024. Between 01/1/24 and 04/12/24 the resident lost 14 pounds or 7.5% total body weight. This constituted a significant change of condition for significant weight loss. In an interview with Resident 3 on 07/16/24 at 10:30 am, they stated they ate their meals independently. Resident 3 also stated they ate all their meals in their room. A surveyor attempted to observe Resident 3's meal intake on 07/18/24 but the Resident refused. There was no documented evidence an RN significant change of condition was completed at the time of the weight loss noted in April of 2024. There was no evidence that interventions were put in place, the nurse participated on the service planning team, or reviewed the service plan with date and signature within 48 hours. In an interview on 07/17/24 at 12:20 pm with Staff 7 (Regional RN) indicated he was aware of the weight loss for the resident and acknowledged the RN assessment of the resident's weight loss was overdue and no interventions were implemented. At the time of survey there were no weights available between 06/12/24 and 07/12/24.  On 07/17/24 the facility was asked to get a current weight for the resident and it was noted as 162 pounds, this was a decrease of six pounds since the last weight was obtained on 05/12/24. The facility's failure to complete an RN assessment within 48 hours that documented findings, resident status and interventions made as a result of the assessment put the resident at risk for ongoing weight loss. The need to ensure the RN documented interventions made as a result of an assessment, the service plan was updated, the licensed nurse participated on the service planning team, or reviewed the service plan with date and signature within 48 hours related to significant change of condition was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), and Staff 7 (Regional RN) on 07/18/24 at 2:00 pm. They acknowledged the findings. 3. Resident 2 moved into the facility in 07/2022 with diagnoses including Parkinson's disease. During the entrance conference on 07/15/24, Staff 2 (Health Services Administrator) and Staff 4 (Resident Services Coordinator, 3rd Floor) reported the resident required two person transfers and meal assistance. Interviews with staff, the resident and family member and review of the resident's clinical record was conducted during the survey. The following was identified: During an interview with Witness 1 (family member) on 07/17/24 at 12:16 pm, it was reported Resident 2 had "a big change since [s/he] was in the hospital with a pretty bad [urinary tract infection] at the end of June [2024]. [S/he] came back after that and [s/he] really declined with eating and mobility." During an interview on 07/18/24 at 10:15 am with Staff 19 (CG), reported "I asked [Staff 4] for a TSP [temporary service plan] because [s/he] can't bear weight anymore and we can't transfer [him/her] with one person anymore." Review of a temporary care plan update dated 07/03/24 noted Resident 2 required two-person transfers. This constituted a significant change of condition requiring an RN assessment. There was no documented evidence an RN completed an assessment which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN completed significant change of condition assessments was discussed on 07/18/24 at 3:16 pm with Staff 1 (ED), Staff 2, Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.

C280 - Resident 3 COC completed on 7/25/2024. PCP was notified and care coordination between home health and mental health was established. Weights will be reviewed bi-weekly in acuity meetings with the resident service coordinator, facility nurse, and health services administrator to ensure significant changes are recognized. Medtech staff will be retrained on specific weight variation guidelines and to notify the facility nurse immediately for follow-up. Resident 2 COC completed and reviewed by the facility RN. The care staff, MedTech and RSC will retrianed on reporting concerns of sudden or significant changes to ADLs, weight, mood, behavior to cognitive status. Health Services Administrator will ensure these bi- weekly acuity meetings occur and will provide printouts of all resident weights for review. Facility nurses will recognize significant changes in condition and review changes in the resident's care plan within 48 hours of noting the change.Health Services Administrator or designee will be responsible for ensuring that the corrections are completed and will provide ongoing oversight.

Based on interview and record review, it was determined the facility failed to coordinate care with outside service providers, ensure staff were informed of new interventions, and that the service plan was adjusted if necessary, in order to ensure the continuity of care for 1 of 2 sampled residents (# 3) who received outside services. Findings include, but are not limited to: During the survey, Resident 3's records were reviewed and staff were interviewed about his/her care needs. The following was identified: Resident 3 received home health PT services for strengthening. S/he started home health services on 04/11/24. Resident 3 was discontinued from this home health program on 05/17/24. The resident was then enrolled into a different home health PT program on 06/04/24 until it was discontinued on 07/11/24. Both home health PT agencies made regular recommendations for staff to do the following: * Assist resident into wheelchair daily and encourage propelling in hallway; * Continue with one to two person transfers; * Follow plan of care on transfers and strengthen. In an interview with Staff 2 (Health Services Administrator) on 07/17/24 at 12:20 pm, she agreed there was no follow up from the facility with outside service providers on the care Resident 1 was being provided, if there were any new interventions or if the service plan required adjustment. There was no documented evidence the facility reviewed these recommendations, informed staff of new interventions, and adjusted the service plan if necessary. The need to coordinate care with on and off-site health care providers, staff are informed of new interventions, and that the service plan was adjusted if necessary was discussed with Staff 1 (ED), Staff 2 and Staff 4 (Resident Service Coordinator 3rd Floor) on 07/18/24 at 2:00 pm. They acknowledged the findings.

C290 - Resident 3's care plan has been updated to incorporate outside provider notes and recommendations. Resident Service Coordinators will review outside provider notes daily and incorporate recommendations into the resident care plan. These notes will then be reviewed by the facility nurse. During bi-weekly acuity meetings, outside provider notes will be reviewed by the RSC, facility nurse, and Health Services Administrator to ensure care plan updates have been made for every outside provider recommendation. Health Services Administrator or designee will be responsible for ensuring that the corrections are completed and will provide ongoing oversight.

2. Resident 8 received home health RN, PT, and OT services prior to admitting to hospice on 11/22/24. Home health PT made recommendations for staff to perform the following: * 11/14/24: "Staff advised to do 2x person assist for transfers - walk only if able/use wheelchair as appropriate to avoid falls. Recommendations made to facility staff." During an interview on 12/04/24 at 11:10 am, Staff 2 (Health Services Administrator) confirmed there was no documented evidence the facility informed staff of new interventions and adjusted the service plan if necessary. The need to coordinate care with on and off-site health care providers, staff were informed of new interventions, and the service plan was adjusted if necessary was discussed with Staff 1 (ED), Staff 2, Staff 34 (Staffing Coordinator), and Staff 10 (Regional RN) who was present via speaker phone on 12/04/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside service providers, ensure staff were informed of new interventions, and the service plan was adjusted if necessary, in order to ensure the continuity of care for 2 of 4 sampled residents (#s 8 and 9) who received outside services. This is a repeat citation. Findings include, but are not limited to: During the survey, Resident 9's records were reviewed and staff were interviewed about his/her care needs. The following was identified: 1. Resident 9 received home health physical therapy (PT) services for strengthening. S/he started home health services on 10/17/24. Home health PT made recommendations for staff to do the following: * 10/17/24: "Reorganize bathroom so that patient can sit at sink in wheelchair and reach sink/needed supplies to clean teeth, brush hair/face, put on makeup"; * 10/23/24: "Patient should still use pendant when needing/wanting to get up"; and * 10/25/24: "Patient should still use pendant when needing/wanting to get up". Resident 9 also started with home health RN on 10/31/24. On 11/04/24, home health RN recommended "practice good position changes to prevent skin injury on the buttocks". In an interview with Staff 7 (Regional RN) on 12/03/24 at 2:38 pm, he agreed there was no follow up from the facility on information obtained from the outside service provider regarding care recommendations, if there were any new interventions or if the service plan required adjustment. There was no documented evidence the facility informed staff of new interventions and adjusted the service plan if necessary. The need to coordinate care with on and off-site health care providers, staff were informed of new interventions, and that the service plan was adjusted if necessary was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 7, and Staff 10 (Regional RN) on 12/04/24 at 11:30 am. They acknowledged the findings.

1. Care plans for Resident 8 and Resident 9 were reviewed. For Resident 8, chart and service plan were updated to reflect new outside provider and admission to hospice. For Resident 9, service plan was updated and TSP created to reflect recommendations made by outside provider. 2. Resident Service Coordinators will review all outside provider notes daily to identify new interventions or updates, ensuring these are incorporated into the care plans. Facility nurses will then verify that the care plans are accurate and complete. 3. During bi-weekly acuity meetings, the Resident Service Coordinator, facility nurse, and Health Services Administrator will review all recommendations from outside providers and ensure that the care plans are properly updated. Monthly audits of a random sample of care plans will be conducted to confirm that all external provider recommendations are accurately documented and executed. 4. Health Services Administrator or designee will be responsible for overseeing these updates.

Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified when a resident refused to consent to a medication order for 1 of 1 sampled resident (#2) who had medication refusals. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2022 with diagnoses including Parkinson's disease and had a history of chronic urinary tract infections (UTI). The resident's current prescriber orders and 06/01/24 to 07/15/24 MARs were reviewed. The following was identified: * The resident was prescribed Nitrofurantion Macro 100 mg capsule every day for recurrent urinary tract infection; and * Staff documented the resident refused the Nitrofurantion Macro medication from 06/25/24 through 07/11/24. There was no documented evidence staff notified the prescriber of the above medication refusals. The need to ensure the physician or other practitioner was notified when a resident refused to consent to a medication order was discussed with with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations) on 07/18/24 at 3:16 pm. They acknowledged the findings.

C305 - Resident 2's PCP was notified about refused medications identified during the survey. The facility will document medication refusal, and staff will notify the physician and Health Services Administrator of refusal, including those by the family or POA. Missed medications are reviewed daily by Health Services Administrator or designee. An Incident Report will be generated for refusal. This system may be overridden if the resident's physician provides specific written instructions for handling the refusal, and the community can implement those instructions. Medtech staff will be retrained on the procedures for completing Incident Reporting. Health Services Administrator or designee will review missed and held medications daily on the EHR system and PCC dashboard.Health Services Administrator or designee will be responsible for ensuring that the corrections are completed and will provide ongoing oversight.

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications and have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (#2) who chose to self-administer their medications. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2022 with diagnoses including Parkinson's disease. During the acuity interview on 07/15/24, staff reported the resident self-administered some of their medications. Review of Resident 2's 05/15/24 evaluation and service plan noted "spouse will administer medication that keeps [sic] in apartment, staff to administer the rest." During an interview with Staff 2 (Health Services Administrator) on 07/17/24 at 1:05 pm, surveyor requested a self-administration of medications evaluation and a signed physician order. The facility provided an evaluation that was completed on 02/28/23. There was no documented evidence the facility updated the self-administration of medications evaluation quarterly and there was no documented evidence the facility had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications. The need to ensure the facility updated the self-administration of medications evaluation quarterly and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was discussed on 07/18/24 at 3:16 pm with Staff 1 (ED), Staff 2, Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.

C325 - The facility submitted an order to the PCP to obtain approval for the resident's spouse to administer PRN and over the counter medications. The facility has order from PCP for spouse to administer medications. The Health Services Administrator and facility nurse will verify that proper orders are in place during acuity meetings when a self medication assessment is due. PCC system will prompt the facility when the self medication assessment is due based on the resident's quarterly assessment date. Health Services Administrator will conduct quarterly audits to ensure compliance. Health Services Administrator or designee will be responsible for ensuring that the corrections are completed and will provide ongoing oversight.

Based on interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to the following: During the entrance conference on 07/15/24 at 10:05 am with Staff 2 (Health Services Administrator) and Staff 4 (Resident Services Coordinator 3rd Floor), the following was identified: * The assisted living was home to 71 residents who resided on three floors; * Four residents required a mechanical lift for transfers. At least one resident who required a mechanical lift resided on each floor of the facility; * Five residents required two-person assist for transfers at all times; * One resident required occasional two-person assist for transfers; and * Sixteen other residents were reported to require high levels of caregiving assistance due to hospice, cognitive decline, need for one-person transfer assistance, need for frequent checks, and/or due to fall risk. The facility's posted staffing plan, the staffing schedule from 07/01/24 through 07/15/24, and the corresponding timeslips were reviewed. The facility's posted staffing plan indicated two caregivers and one medication technician were scheduled to work the 10:00 pm to 6:00 am shift daily. This was confirmed in an interview with Staff 2 (Health Services Administrator) on 07/18/24 at 11:16 am. On 07/17/24 at 1:19 pm, Staff 32 (Staffing Coordinator) reported the two overnight caregivers were assigned to specific floors, but they were expected to assist on other floors as needed. He also reported the one overnight MT provided occasional assistance with two-person transfers or required resident checks, but caregiving was not the focus of the MT's job. The facility lacked a sufficient number of overnight staff to meet the scheduled and unscheduled needs and fire evacuation standards of the multiple residents who required the assist of two care staff for transfers, had high levels of care needs, and resided on three distinct floors. The need to have a sufficient number of staff in to meet all scheduled and unscheduled needs of residents on the overnight shift was discussed with Staff 1 (ED), Staff 2, Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations) on 07/18/24 at 2:32 pm. They acknowledged the findings.

C360 - Community staffing levels have been adjusted to meet 24 hour scheduled and unscheduled needs of each resident to meet fire safety evacuation standards during night shift. needs of residents requiring two staff members for transfers on all shifts, based on ABST. Ongoing evaluations and reviews of staffing will be conducted with each resident move-in and change in care needs. Health Services Administrator will review staffing requirements weekly and make adjustments as needed to ensure adequate staffing for residents' needs.Health Services Administrator or designee and Executive Director will be responsible for ensuring that the corrections are completed and will provide ongoing oversight

Based on interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated quarterly, addressed the amount of staff time needed to provide care for 1 of 4 sampled residents (#3) and multiple unsampled residents to determine appropriate staffing levels for the facility, and to meet the 24-hour scheduled and unscheduled needs of residents. Findings include, but are not limited to: During the acuity interview on 07/15/24, 22 residents were identified as requiring two-person care, two-person transfers with mechanical lift, had falls with injuries, and/or were on hospice. The facility's ABST was reviewed with Staff 4 (Resident Services Coordinator 3rd floor) and Staff 8 (Health Services Quality Coordinator) on 07/16/24 at 11:05 am. The following was identified: * Resident 3's ABST was not accurate for staff time needed to provide care; * Resident 4's ABST was not updated at least quarterly; * Three unsampled residents were not entered into the facility's ABST; and * 19 unsampled residents had not been updated quarterly. The need to ensure the ABST was updated quarterly, addressed the amount of time needed to provide resident care and ensured all residents were entered into the ABST was discussed on 07/18/24 at 3:16 pm with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 6 (RN), Staff 7 (Regional RN), Staff 8, Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.

C361 - The ABST has been updated for resident 2 and 4 along with the unsampled residents have been into the ABST. Health Services Administrator will provide additional education to Resident Service Coordinators on how to update the ABST tool and ensure it is done in a timely manner. RSC checklist for pre-service planning will be revised to include reminders to update the ABST at move-in, 30 days after move-in, quarterly, and as needed. ABST will be updated and verified for accuracy around the time of the quarterly evaultions and during any significant change in condition. RSC will open and close the resident's ABST even if no changes have occurred, to create a time stamp for evaluating the need for any updates. Health Services Administrator or designee and Executive Director will be responsible for ensuring that the corrections are completed and will provide ongoing oversight.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission 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 and failed to re-instruct residents at least annually. Findings include, but are not limited to: On 07/16/24 at 10:10 am, the surveyor discussed the facility's process and documentation for instructing residents on fire and life safety procedures with Staff 1 (ED). Staff 1 reported that the Resident Services Coordinator met with each new resident within 24 hours of move-in to provide the required fire safety instruction, then documented this within the resident record. Staff 1 also reported that all residents were re-instructed quarterly at each care conference. Documentation was requested for initial fire safety instruction for Resident 5 and the most recent fire safety re-instruction for Resident 6. No documentation was provided. On 07/18/24 at 2:43 pm, the need to ensure fire and life safety instruction was provided to residents upon admission and at least annually was discussed with Staff 1, Staff 2 (Health Services Administrator), Staff 6 (RN), Staff 7 (Regional RN), Staff 8 (Health Services Quality Coordinator), Staff 9 (Regional Director), and Staff 11 (Director of Resident Relations). They acknowledged the findings.

C422 - Health Services Administrator met with resident and reviewed fire and life safety training with them. They signed off on an acknowledgment document that has been added to their chart. has worked with Resident Service Coordinators to explain fire and life safety training expectations for new move-in residents. All residents will be educated about Fire and life safety by 9/16/2024. Once training is completed, the document is signed by the resident or POA and placed in their chart. Fire and life safety training will be explained by the RSC during new move-in care plan meetings, which will take place before or on the day of move-in. Ongoing fire and life safety training will be incorporated into resident townhall meetings on a bi- annual basis. Health Services Administrator or designee will provide overisght to ensure that these trainings are conducted as scheduled.

Based on observation and interview, it was determined the facility failed to ensure the interior areas were kept clean and in good repair. Findings include, but are not limited to: Observations of the facility on 07/15/24 through 07/18/24 identified the following areas were in need of cleaning or repair: * Laundry rooms located on the 1st, 2nd, and 3rd floors had dirt buildup on the transition strips of the doorways and floors. There was a buildup of lint, dust and debris behind the laundry appliances; * First floor laundry room had walls that were missing paint or drywall and were not cleanable surfaces; * First floor laundry room had a leaking pipe that was discoloring the floor; * The laminate counter on the 3rd floor laundry room was chipped; and * Carpet throughout all three floors of the ALF were stained and soiled. The need to ensure the interior areas of the facility were kept clean and in good repair were discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 3 (Plant Operations), and Staff 11 (Director of Resident Relations) on 07/17/24 at 2:00 pm. They acknowledged the findings.

C613 - The facility will address the identified issues in the laundry rooms and throughout the ALF as follows: Dirt buildup on transition strips and behind laundry appliances on the 1st, 2nd, and 3rd floors has been cleaned. The first-floor laundry room has been repaired, including repaint of walls to ensure they are cleanable and repair of the leaking pipe. The chipped laminate counter in the third-floor laundry room has been repaired. Carpets throughout all three floors will be cleaned and treated to remove stains. The Executive Director and Director of Plant Operations will conduct a bi-monthly walk through of all areas to assess the need for any additional maintenance or repairs. Executive Director and Director of Plant Operations will be responsible for ensuring that these corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) following a significant change of condition for 1 of 1 sampled resident (# 8), and failed to consistently staff to meet or exceed the posted staffing plan 24 hours a day, seven days a week. Findings include, but are not limited to: Review of the ABST, the 11/24/24 through 11/30/24 staffing schedule, and the posted staffing plan was completed on 12/02/24 through 12/04/24 and the following were found: a. Resident 8, who experienced a significant change of condition on 11/22/24, was last updated on 09/30/24. b. Review of the facility's posted staffing plan indicated the following: * Three MTs and five CGs were scheduled for day and swing shift (6:00 am to 2:00 pm) and (2:00 pm to 10:00 pm), respectively; and * One MT and three CGs were scheduled for the overnight (NOC) shift (10:00 pm to 6:00 am). Review of the facility's staffing schedule from 11/24/24 through 11/30/24 revealed the following: * 1 of 7 days two MT's were scheduled for swing shift; and * 4 of 7 days two caregivers were scheduled for NOC shift. The facility's staffing schedule was reviewed with Staff 2 (Health Services Administrator) on 12/04/24 at 9:05 am and she confirmed she routinely scheduled one MT and three caregivers for NOC shift but acknowledged the facility's staffing plan was not consistently followed. The need to ensure residents' ABST was updated with significant changes of condition, and consistently followed the facility's staffing plan was discussed with Staff 1 (ED), Staff 2, Staff 5 (Resident Services Coordinator), and Staff 34 (Staffing Coordinator) and Staff 10 (Regional RN), who was present via speaker phone, on 12/04/24. They acknowledged the findings.

1. ABST for Resident 8 was updated during the survey visit when the change was identified. 2. Additional education will be provided to Resident Service Coordinators on updating the ABST to ensure it is revised for significant changes, including at move-in, 30 days after move-in, quarterly, and during any necessary evaluations. 3. ABST will be updated and verified for accuracy around the time of the quarterly evaluations and following any significant change in condition. Health Services Administrator or designee and Executive Director will be responsible for ensuring that these corrections are completed and will provide ongoing oversight. The community will ensure that staffing is consistently scheduled to meet the posted staffing plan for all shifts. Staffing schedule will be reviewed weekly to ensure it aligns with the posted plan, including the appropriate number of staff for each shift. If discrepancies are identified, staffing will be adjusted as necessary to ensure compliance with the staffing plan. Health Services Administrator and Staffing Coordinator will work together to monitor and review the staffing schedule, ensuring adherence to the posted plan. 4. Health Services Administrator or designee and the Executive Director will be responsible for ensuring these corrections are completed.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C260, C270, and C290.

Refer to C260, C270, C290

The findings of the re-licensure survey, conducted 07/15/24 through 07/18/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit of the re-licensure survey of 07/18/24, conducted 12/02/24 through 12/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 07/18/24, conducted on 04/02/25 through 04/03/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 03/05/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: a. Food spills/splatters, debris, dust and/or grease were observed on or underneath the following: * Walk in refrigerator and freezer floors; * Refrigerator #7's interior bottom shelf; * Freezer next to the deep fat fryer's interior bottom shelf; * Lower shelves throughout the kitchen including under the steam table and prep area tables;   * Dry storage shelves with pans holding food items and shelves with plastic barriers; * Exterior oven doors; * Hood vents above and walls behind stoves/grills/steam jacketed kettle, tilt pan; * Pan food slicer was sitting on; and * Dishroom wall behind the sink spray hose. Additional observation included: * Improper use of gloves including not washing hands between changes, using same gloves to handle several food items, wearing gloves to retrieve food items from refrigerator and returning to handle food items with same gloves. Not using gloves when preparing ready to eat items. Not using beard restraints while preparing/serving food; * Dishes stored on lowest shelf in the area across from the dishwashing area were stored in a manner that could cause cross contamination; * Food on rolling carts in walk in refrigerator were uncovered/undated/unlabeled; * Three large tubs of food being cooled with frozen wands were not covered tightly; * The freezer next to the deep fat fryer had open bags and uncovered tubs of food; * Garbage cans were not covered when not in use; and * Lack of beard restraints while preparing and serving food. The areas of concerned were discussed with Staff 1 (Executive Chef), Staff 2 (Food & Beverage Director), Staff 3 (Executive Director), Staff 4 (ALF Administrator) and Staff 5 (MCC Administrator) on 03/25/24. The findings were acknowledged.

Kitchen staff did a thorough deep cleaning of all kitchen and storage areas that was completed on 3/18/24. The Executive Chef placed this cleaning duty on daily cleaning list. This list will be completed by kitchen staff on a daily basis.  The Executive Chef and/or Sous Chef will ensure this daily cleaning task is completed and continue to monitor. o Kitchen staff completed a detailed cleaning of the walk in refrigerator and freezers on 3/15/24 . The Executive Chef added a twice daily sweep and mop of the cooler spaces to the daily cleaning list. This list will be completed by kitchen staff on a daily basis.  The Executive Chef and/or Sous Chef will ensure this daily cleaning task is completed and continue to monitor. o All lower shelves in the refrigerator, near the freezer next to the deep fat fryer, and below the steam table and prep area tables were thoroughly cleaned  on 3/16/24. These cleaning tasks were added to daily cleaning list by Executive Chef. This list will be completed by kitchen staff on a daily basis. The Executive Chef and/or Sous Chef will ensure this daily cleaning task is completed and continue to monitor. o All plastic sheets in dry storage to be removed and all racks will be properly cleaned by 3/20/24. This cleaning tasks was added to daily cleaning list by Executive Chef. This list will be completed by kitchen staff on a daily basis. The Executive Chef and/or Sous Chef will ensure this daily cleaning task is completed and continue to monitor. o Exterior oven doors, the hood vents, and the walls behind the stoves/grills/steam jacketed kettle, and the tilt pan will be cleaned by 5/4/2024. Moving forward these items will be cleaned weekly and sometimes daily as needed. These cleaning tasks were added to the weekly cleaning list by the Executive Chef. This list will be completed by kitchen staff on a weekly basis. The Executive Chef and/or Sous Chef will ensure this weekly cleaning task is completed and continue to monitor. o Beginning on 3/18/24 or sooner the slicer pan is being replaced daily. This item was added to the daily checklist for the Sous Chefs. The Executive Chef will oversee the Sous Chefs to ensure they are completing their daily checklists and the Executive Chef will continue to monitor. o All dishes on lower shelving are being stored inverted as of 3/15/24. This item was added to the daily checklist for the Sous Chefs. The Executive Chef will oversee the Sous Chefs to ensure they are completing their daily checklists and the Executive Chef will continue to monitor.   o Kitchen staff completed a detailed cleaning of the wall behind the sink spray hose on 3/15/24 . This cleaning tasks was added to the daily cleaning list by the Executive Chef. This list will be completed by kitchen staff on a daily basis. The Executive Chef and/or Sous Chef will ensure this daily cleaning task is completed and continue to monitor. o As of 3/5/2024 all food items in the walk-in coolers have the proper covers and labels. This item was added to the daily checklist for the Sous Chefs. The Executive Chef will oversee the Sous Chefs to ensure they are completing their daily checklists and the Executive Chef will continue to monitor. o As of 3/5/2024 all items in the walk-in and smaller freezer are stored in closed containers and/or properly sealed packaging. This item was added to the daily checklist for the Sous Chefs. The Executive Chef will oversee the Sous Chefs to ensure they are completing their daily checklists and the Executive Chef will continue to monitor. o The Food and Beverage Director ordered new spin top lids to replace broken flip top lids. Lids ordered on 3/6/24 by the Food and Beverage Director. These lids will be installed upon arrival by the Executive Chef. The Executive Chef will monitor these lids on a daily basis and replace them as needed.   o As of 3/21/24 beard restraints were required to be worn by all kitchen staff with facial hair. This will be checked daily by the Executive Chef and/or Food and Beverage Director. o As of 3/28/24 all kitchen staff were retrained on the use of gloves in a kitchen workplace. This item was added to the daily checklist for the Sous Chefs to ensure all employees are properly using gloves. The Executive Chef will oversee the Sous Chefs to ensure they are completing their daily checklists and the Executive Chef will continue to monitor.

The findings of the kitchen inspection, conducted 03/05/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 03/05/24, conducted 05/16/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to: Observation of the kitchen on 02/16/23 at 11:45 am, revealed the following areas were in need of cleaning and/or repair: * Baseboards, ledges and lower wall areas throughout the kitchen perimeter had accumulated food particles, dust and brown matter; * Floors in the walk-in freezer had food particles and dried spills; * Multiple cutting boards had gouges and a build-up of food matter on the surfaces; * Trash receptacles with food debris did not have lids; * The secured cutting board installed along the length of the sandwich prep table had gouges and a build-up of food matter on the surface; and * Multiple open packages in the dry storage area were unsecured or sealed to prevent cross contamination. On 02/16/23 at 1:30 pm the areas requiring cleaning and/or repair were reviewed with Staff 1 (Administrator) and Staff 2 (Culinary Director). They acknowledged the findings.

Citations: Baseboards, ledges and lower wall areas throughout the kitchen perimeter had accumulated food particles, dust and brown matter. Plan of Correction: Kitchen staff completely scrubbed all walls on 2/16/2023.  They degreased all walls. The Executive Chef placed this cleaning duty on weekly cleaning list. This list will be completed by kitchen staff on a weekly basis.  The Executive Chef and/or Sous Chef will ensure this weekly cleaning task is completed and continue to monitor. Citation: Floors in the walk-in freezer had food particles and dried spills. Plan of Correction: The freezer has been swept and mopped as of 2/17/2023. The freezer floor will be swept and mopped on a weekly basis.  The ongoing process of sweeping and mopping will be a weekly task to be monitored by the Executive Chef and the Sous Chefs. Citation: Multiple cutting boards had gouges and a build-up of food matter on the surfaces. Plan of Correction: All new cutting boards have been purchased and the old cutting boards will be thrown out.  In the future cutting boards will be replaced as soon as gouges appear. The Executive Chef will monitor cutting boards on a weekly basis to ensure they don't have gouges or a build-up of food matter. New cutting boards arrived on 3/1/2023. Citation: Trash receptacles with food debris did not have lids. Plan of Correction: All new lids for trash cans have been purchased, 16 in total.  The first set arrived on 2/28/2023.  The next set of trash can lids arrived on 3/6/2023. The Food and Beverage Director or the Executive Chef will monitor trash can lids on a monthly basis to ensure they are all in good working order. Citation: The secured cutting board installed along the length of the sandwich prep table had gouges and a build-up of food matter on the surface. Plan of Correction: All new cutting boards have been purchased for the secured stations. Old cutting boards were removed and we bought a scraper to refinish the older cutting board. We will put the older cutting board back into rotation if they can be properly refinished and free of gouges or food matter. In the future cutting boards will be replaced or scraped as soon as gouges appear. The Executive Chef will monitor cutting boards on a weekly basis to ensure they don't have gouges or a build-up of food matter. New cutting boards arrived on 2/28/2023. Citation: Multiple open packages in the dry storage area were unsecured or sealed to prevent cross contamination. Plan of Correction: All open packages to be dated when opened, placed into food storage containers or wrapped in plastic. Open packages can also be placed in ziplocks and sealed. All items have been stored properly as of 2/17/2023.  Executive Chef and/or Sous Chefs to monitor and correct issues with staff on a daily basis.  Signs stating the policy have been hung up in the storeroom.

The findings of the kitchen inspection, conducted on 02/16/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first re-visit of the kitchen inspection of 02/16/23, conducted 05/01/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.