Shore Pines Senior Living.

“Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 09/10/24 and 08/11/24 showed the following areas needed cleaning or repair. * Drips, splatters and/or debris were observed inside cupboards, under shelves, inside drawers, behind the ice machine and on the walls throughout the kitchen and dry storage; * Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment and at the door edges. Several sections of flooring around the kitchen a black/brown haze. Multiple seams were cracked or pulling apart, large cracks were present between patched flooring areas, thick areas with missing caulking and missing pieces of flooring were noted in several areas of the kitchen; * Shelving in multiple refrigerators and/or freezer units had spills, debris, white accumulation with dangling pieces, rust and/or chipped/peeling/cracked shelf coating; * Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board and/or bubbling paint. Open shelving and cupboards on both sides of the steam table had heavily stained or discolored shelves with clean dishes stored on them. Additional open shelving units under the drink station had dark stains, debris and chips/dings and exposed particle board; * Chipped laminate was noted on counter edges; * Baseboards were pulling away from the wall near the freezer/refrigerator units; * Three cutting boards were significantly worn, grooved and stained; * Two frying pans, one small and one large, and three pots, one small, one medium and one extra-large, had significant carbon build up with dented and/or pitted pot bottoms; * Caulking around the handwashing sink was discolored black/gray and cracked; * Debris was noted on top of the dish machine; * Ceiling vent near dry storage had significant thick dust buildup; * The wall on the “dirty” side of the dishwashing area had a long area of dark black discoloration along the grout line between the wall and metal back splash; * Dust buildup was noted on the vents to the ice machine; * Freezer unit was not operating properly at the time of survey. The temperature of the freezer was between 30 and 34 degrees. Frozen items had been removed and items requiring refrigeration were being stored in the unit. The unit had been broken for 2-3 days at the time of survey with multiple previous repairs noted per staff and a request for repair submitted for current issue; * Both ovens were not maintaining appropriate temperatures based on the selected temperature on the dial. Per staff the left side ran much higher than the temperature dial indicated, the right-side temperature ran low compared to the dial selection. Multiple staff indicated the right oven was primarily used for desserts to avoid any issues with undercooking; * Spills and debris noted to the shelves and on top of items in the dry storage area as well as debris underneath shelving units; The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Sister Facility ED), Staff 2 (Dietary Services Manager) and Staff 3 (Cook) on 09/10/24. The staff acknowledged the findings. Repair or Replacement -kitchen floor”

“Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C240. OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C240. This is being repiared and fixed by maintenance director and his replacement and will be in compliance before next revisit OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:”

“Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C240 1: A thorough, professional cleaning of the entire kitchen will be completed, All refrigerators, freezers, and dry storage areas will be thoroughly cleaned, including removal of spills, rust, and debris. 2: A revised cleaning schedule will be implemented, with daily, weekly, and monthly cleaning tasks assigned to the kitchen staff. 3. Weekly audits will be conducted by the Dietary Services Manager to ensure cleanliness and adherence to the new cleaning schedule. 4: ED and DSM will monitored and completed. OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C240. OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C240.”

“Based on observation, interview, and record review, conducted during a site visit on 04/23/24, it was determined the facility did not provide assistance with cleaning dishes for 1 of 1 sampled resident (#1). Findings include, but are not limited to: In an interview on 04/23/24 at 11:06 am, Staff 1 (ED) indicated kitchen and housekeeping staff are to provided Resident 1 with daily assistance with cleaning dishes. In an interview on 04/23/24 at 1:01 pm, Resident 1 stated staff are not providing assistance with cleaning his/her daily dishes. In an interview on 04/23/24 at 2:30 pm, Staff 2 (Housekeeping) stated he/she does not provide assistance with daily dishes, "they are told by management not to do them, the kitchen staff will come get them or the Resident will do them." CS reviewed Resident 1 service plan dated 03/15/24 that confirmed assistance with cleaning daily dishes. CS observed Resident 1 had dirty dishes in his/her apartment sink. The above information was shared with Staff 1 on 04/23/24. S/he acknowledged the findings. It was determined the facility does not provide assistance with cleaning daily dishes. VPOC: ED reports the facility is developing a new cleaning check list for housekeeping and care staff that will include completing residents' daily dishes as part of the routine. As well kitchen staff will do a daily check of residents' rooms for dishes after each meal. ED reports this will start the beginning of May 2024. Based on observation, interview, and record review, conducted during a site visit on 04/23/24, it was determined the facility did not provide assistance with cleaning dishes for 1 of 1 sampled resident (#1). Findings include, but are not limited to: In an interview on 04/23/24 at 11:06 am, Staff 1 (ED) indicated kitchen and housekeeping staff are to provided Resident 1 with daily assistance with cleaning dishes. In an interview on 04/23/24 at 1:01 pm, Resident 1 stated staff are not providing assistance with cleaning his/her daily dishes. In an interview on 04/23/24 at 2:30 pm, Staff 2 (Housekeeping) stated he/she does not provide assistance with daily dishes, "they are told by management not to do them, the kitchen staff will come get them or the Resident will do them." CS reviewed Resident 1 service plan dated 03/15/24 that confirmed assistance with cleaning daily dishes. CS observed Resident 1 had dirty dishes in his/her apartment sink. The above information was shared with Staff 1 on 04/23/24. S/he acknowledged the findings. It was determined the facility does not provide assistance with cleaning daily dishes. VPOC: ED reports the facility is developing a new cleaning check list for housekeeping and care staff that will include completing residents' daily dishes as part of the routine. As well kitchen staff will do a daily check of residents' rooms for dishes after each meal. ED reports this will start the beginning of May 2024.”

“Based on record review and interview, conducted during a site visit on 04/23/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled Resident (#1). Findings include, but are not limited to: During a review of Resident 1's MAR dated 05/01/22 through 05/31/22, incident report dated 05/26/22, progress notes dated 05/26/22 through 0531/22 and Physicians orders dated 02/16/22 the following deficiency was identified: -On 05/26/22 Resident 1 was administered wrong medication by MT at 5 pm. -Incident report dated 05/26/22 states the following:  MT accidently grabbed the wrong residents pre-popped cup of medication and gave it to Resident 1. MT did not notice the error until after leaving Resident 1's room and putting the empty cup back into medication cart. MT immediately notified RSM, RSM called Nurse and instructed MT to call PCP. -MAR indicated Resident 1 was placed on alert charting for medication error 05/26/22. -Progress notes indicated medication error received wrong medication 05/26/22. On 05/31/22 Nursing notes/monitoring for medication error, Resident reports no side effects or negative outcomes. -Incident report dated 05/26/22 and progress notes dated 05/31/24 confirm Resident 1 had not been administered the following medication in error: Coumadin and Ursodiol both of which Resident 1 does not have a doctor's order for. In an interview on 04/20/24 at 11:16 am Staff 1 (Executive Director) stated at the time the incident happened MT were pre-popping medication, and this caused medications errors. She/he stated pre-popping medication is no longer allowed. She/he stated MT are to only pop medication at the time it is given one medication and one Resident at a time. In an Interview on 04/20/24 at 2:45 pm Resident 1 stated she/he doesn't remember the incident but doesn't have any issues or concerns about his/her medication administration at this time. The above information was shared with Staff 1 on 04/23/24. S/he acknowledged the findings. It was confirmed the facility failed to carry out medication and treatment orders as prescribed for Resident 1. VPOC: ED reports that staff no longer pre-pop medications, all medications are dispensed and passed individually with each resident this has helped ensure less medication errors. Based on record review and interview, conducted during a site visit on 04/23/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled Resident (#1). Findings include, but are not limited to: During a review of Resident 1's MAR dated 05/01/22 through 05/31/22, incident report dated 05/26/22, progress notes dated 05/26/22 through 0531/22 and Physicians orders dated 02/16/22 the following deficiency was identified: -On 05/26/22 Resident 1 was administered wrong medication by MT at 5 pm. -Incident report dated 05/26/22 states the following:  MT accidently grabbed the wrong residents pre-popped cup of medication and gave it to Resident 1. MT did not notice the error until after leaving Resident 1's room and putting the empty cup back into medication cart. MT immediately notified RSM, RSM called Nurse and instructed MT to call PCP. -MAR indicated Resident 1 was placed on alert charting for medication error 05/26/22. -Progress notes indicated medication error received wrong medication 05/26/22. On 05/31/22 Nursing notes/monitoring for medication error, Resident reports no side effects or negative outcomes. -Incident report dated 05/26/22 and progress notes dated 05/31/24 confirm Resident 1 had not been administered the following medication in error: Coumadin and Ursodiol both of which Resident 1 does not have a doctor's order for. In an interview on 04/20/24 at 11:16 am Staff 1 (Executive Director) stated at the time the incident happened MT were pre-popping medication, and this caused medications errors. She/he stated pre-popping medication is no longer allowed. She/he stated MT are to only pop medication at the time it is given one medication and one Resident at a time. In an Interview on 04/20/24 at 2:45 pm Resident 1 stated she/he doesn't remember the incident but doesn't have any issues or concerns about his/her medication administration at this time. The above information was shared with Staff 1 on 04/23/24. S/he acknowledged the findings. It was confirmed the facility failed to carry out medication and treatment orders as prescribed for Resident 1. VPOC: ED reports that staff no longer pre-pop medications, all medications are dispensed and passed individually with each resident this has helped ensure less medication errors.”

“Based on interview, and record review, conducted during a site visit on 04/23/24, it was determined the facility does provide assistance with ambulation for 1 of 1 sampled resident (#1). Findings include, but are not limited to: In an interview on 04/23/24 at 11:06 am, Staff 1 (ED) indicated staff provided Resident 1 with ambulation assistance to and from dining room for meals. In an interview on 04/23/24 at 1:01 pm, Resident 1 stated staff was providing assistance with ambulation to dining room for meals. She/he stated no issues or concerns with ambulation to and from meals at this time. CS reviewed Resident 1 service plan dated 03/15/24 and observations notes dated 02/01/24 through 03/31/24 that indicated assistance with ambulation to and from dining room for meals. The above information was shared with Staff 1 on 04/23/24. S/he acknowledged the findings. It was determined the facility does provide assistance with ambulation. Based on interview, and record review, conducted during a site visit on 04/23/24, it was determined the facility does provide assistance with ambulation for 1 of 1 sampled resident (#1). Findings include, but are not limited to: In an interview on 04/23/24 at 11:06 am, Staff 1 (ED) indicated staff provided Resident 1 with ambulation assistance to and from dining room for meals. In an interview on 04/23/24 at 1:01 pm, Resident 1 stated staff was providing assistance with ambulation to dining room for meals. She/he stated no issues or concerns with ambulation to and from meals at this time. CS reviewed Resident 1 service plan dated 03/15/24 and observations notes dated 02/01/24 through 03/31/24 that indicated assistance with ambulation to and from dining room for meals. The above information was shared with Staff 1 on 04/23/24. S/he acknowledged the findings. It was determined the facility does provide assistance with ambulation.”

“The findings of the change of ownership survey conducted 01/29/24 through 02/01/24 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily 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 change of ownership survey conducted 01/29/24 through 02/01/24 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily 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 02/01/24, conducted 09/10/24 through 09/11/24, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily 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 02/01/24, conducted 09/10/24 through 09/11/24, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily 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 02/01/24, conducted 02/04/25, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily 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 02/01/24, conducted 02/04/25, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the third revisit to the re-licensure survey of 02/01/24, conducted 06/18/25, 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, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. The findings of the third revisit to the re-licensure survey of 02/01/24, conducted 06/18/25, 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 Facilitie”

“Based on interview and record review, it was determined the facility failed to ensure initial evaluations addressed all required components for 1 of 1 sampled resident (#1) whose evaluation was reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 11/2023. Resident 1's initial evaluation failed to address the following required components: * Customary routines; * Spiritual, cultural, social, leisure activities; * Mental health status including history of treatment and effective non-drug interventions; * Personality including how the person copes with change or challenging situations; * Pain including location of pain and pharmaceutical and non-pharmaceutical interventions; * Skin condition; * Emergency evacuation ability; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Elopement risk or history; and * Environmental factors that impact the resident's behavior including, but not limited to, noise, lighting, room temperature. The need to ensure initial evaluations included all required components was discussed with Staff 1 (ED) and Staff 2 (RN) on 02/01/24. The staff acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure initial evaluations addressed all required components for 1 of 1 sampled resident (#1) whose evaluation was reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 11/2023. Resident 1's initial evaluation failed to address the following required components: * Customary routines; * Spiritual, cultural, social, leisure activities; * Mental health status including history of treatment and effective non-drug interventions; * Personality including how the person copes with change or challenging situations; * Pain including location of pain and pharmaceutical and non-pharmaceutical interventions; * Skin condition; * Emergency evacuation ability; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Elopement risk or history; and * Environmental factors that impact the resident's behavior including, but not limited to, noise, lighting, room temperature. The need to ensure initial evaluations included all required components was discussed with Staff 1 (ED) and Staff 2 (RN) on 02/01/24. The staff acknowledged the findings.”

“Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status, needs and preferences, and provided clear direction to staff for 2 of 2 sampled residents (#s 1 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 06/2022 with diagnoses including respiratory failure with hypoxia and was observed to be wearing oxygen via nasal cannula throughout the survey. Oxygen was supplied via a concentrator or by individual tanks when the resident was not near the concentrator. The most recent service plan, dated 01/30/24, and interim service plans were reviewed. The service plan did not reflect the resident's needs and provide clear direction to staff in the following area: * Use of oxygen, including setting, cleaning and tube replacement information. The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 02/01/24. They acknowledged the findings. Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status, needs and preferences, and provided clear direction to staff for 2 of 2 sampled residents (#s 1 and 5) whose service plans were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 1 and 3) who had documented medication and treatment refusals. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 10/2023 with diagnoses including bipolar disorder and chronic pain. A review of Resident 3's 01/01/24 - 01/30/24 MAR identified the resident refused medications on 67 occasions. There was no documented evidence the physician had been notified of the refusals. The need to notify the practitioner of resident medication refusals was discussed with Staff 1 (ED) and Staff 2 (RN) on 02/01/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 1 and 3) who had documented medication and treatment refusals. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure residents' MARs were complete, accurate, and provided clear instruction and parameters for administration of scheduled and PRN medications for 3 of 4 sampled residents (#s 1, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 11/2023 with diagnoses including chronic pain. The resident's 01/01/24 through 01/29/24 MAR and physician orders were reviewed and revealed the following: * Multiple PRN pain medications including Tylenol 1000 mg, Tramadol 50 mg and Norco 5/325 mg, lacked clear parameters related to when and in what sequence they should be administered; and * Multiple PRN bowel management medications lacked clear parameters related to when and in what sequence they should be administered. The need to ensure MARs were complete and included clear direction to staff for medication administration was discussed with Staff 1 (ED) and Staff 2 (RN) on 02/01/24. The staff acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure residents' MARs were complete, accurate, and provided clear instruction and parameters for administration of scheduled and PRN medications for 3 of 4 sampled residents (#s 1, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) to accurately reflect all the ADLs for each resident, including the amount of staff time needed to provide care for 4 of 4 sampled residents (1, 2, 3 and 4). Findings include, but not limited to: The facility's ABST was reviewed with Staff 1 (ED) on 01/31/24. During interviews with staff and observations of resident care, the current ADL needs for multiple sampled residents were not reflective in the ABST, including an accurate amount of staff time needed to provide care. The need to ensure all time needed for providing ADL care to residents was accurate in the ABST tool was reviewed with Staff 1 on 01/31/24 and 02/01/24. The staff acknowledged the findings. No additional information was provided. Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) to accurately reflect all the ADLs for each resident, including the amount of staff time needed to provide care for 4 of 4 sampled residents (1, 2, 3 and 4). Findings include, but not limited to: The facility's ABST was reviewed with Staff 1 (ED) on 01/31/24. During interviews with staff and observations of resident care, the current ADL needs for multiple sampled residents were not reflective in the ABST, including an accurate amount of staff time needed to provide care. The need to ensure all time needed for providing ADL care to residents was accurate in the ABST tool was reviewed with Staff 1 on 01/31/24 and 02/01/24. The staff acknowledged the findings. No additional information was provided.”

“Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for multiple unsampled residents and failed to develop an accurate staffing plan for each shift, that met the scheduled and unscheduled needs of all residents. Findings include, but are not limited to: On 02/04/25 at 11:30 am, Staff 2 (RN, Manager on Duty) provided the surveyor with a list of the current residents residing in the facility. The facility's ABST was reviewed and compared to the current resident list and the following was identified: * Five unsampled residents were not entered into the ABST; * Two unsampled residents who shared a unit were not listed as separate individuals in the ABST; and * Four residents were entered into the facility's ABST but were not in the facility at the time of the survey. On 02/04/25 at 2:30 pm, Staff 2 acknowledged the facility's ABST did not have all the current residents entered and four of the residents were no longer in the building. Therefore, the tool did not accurately determine the correct amount of staff time required to provide care to the residents and could not meet the scheduled and unscheduled needs of the residents. The need to ensure the facility's ABST included all residents to determine appropriate staffing levels for the facility to meet the 24-hour scheduled and unscheduled needs of the residents was discussed with Staff 2 on 02/04/25. She acknowledged the findings. Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for multiple unsampled residents and failed to develop an accurate staffing plan for each shift, that met the scheduled and unscheduled needs of all residents. Findings include, but are not limited to: On 02/04/25 at 11:30 am, Staff 2 (RN, Manager on Duty) provided the surveyor with a list of the current residents residing in the facility. The facility's ABST was reviewed and compared to the current resident list and the following was identified: * Five unsampled residents were not entered into the ABST; * Two unsampled residents who shared a unit were not listed as separate individuals in the ABST; and * Four residents were entered into the facility's ABST but were not in the facility at the time of the survey. On 02/04/25 at 2:30 pm, Staff 2 acknowledged the facility's ABST did not have all the current residents entered and four of the residents were no longer in the building. Therefore, the tool did not accurately determine the correct amount of staff time required to provide care to the residents and could not meet the scheduled and unscheduled needs of the residents. The need to ensure the facility's ABST included all residents to determine appropriate staffing levels for the facility to meet the 24-hour scheduled and unscheduled needs of the residents was discussed with Staff 2 on 02/04/25. She acknowledged the findings. There are no detail notes for this visit.”

“Based on observation, interview, and record review, it was determined the facility failed to complete or update and review the ABST evaluation for each resident before a resident moved in and no less than quarterly, and use the results of an ABST to develop and routinely update the facility's posted staffing plan. Findings include, but are not limited to: Review of the facility's ABST entries, staff schedule, calculated staffing hours, and posted staffing plan were completed and showed the following: * Five residents were not entered into the ABST; * Four residents who no longer resided in the facility were still reflected in the ABST resident list; * Updates to the ABST were not made at least quarterly for 35 residents currently residing in the facility; and * The posted staffing plan did not reflect the number of staff working on the floor. The need to ensure the ABST was completed, updated, or reviewed for each resident before a resident moved in and no less than quarterly and to use the results of an ABST to develop and routinely update the facility's posted staffing plan was reviewed with Staff 2 (RN, Manager on Duty) on 02/04/24. She acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to complete or update and review the ABST evaluation for each resident before a resident moved in and no less than quarterly, and use the results of an ABST to develop and routinely update the facility's posted staffing plan. Findings include, but are not limited to: Review of the facility's ABST entries, staff schedule, calculated staffing hours, and posted staffing plan were completed and showed the following: * Five residents were not entered into the ABST; * Four residents who no longer resided in the facility were still reflected in the ABST resident list; * Updates to the ABST were not made at least quarterly for 35 residents currently residing in the facility; and * The posted staffing plan did not reflect the number of staff working on the floor. The need to ensure the ABST was completed, updated, or reviewed for each resident before a resident moved in and no less than quarterly and to use the results of an ABST to develop and routinely update the facility's posted staffing plan was reviewed with Staff 2 (RN, Manager on Duty) on 02/04/24. She acknowledged the findings. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 11 and 12) had documentation of first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Review of the facility's training records on 01/31/24 with Staff 3 (Business Office Manager) revealed the following: * Staff 11 (CG) and 12 (CG), hired on 09/22/23 and 11/20/23 respectively, lacked documentation of abdominal thrust/first aid training within 30 days of hire. On 01/31/24, the lack of documentation, staff training program and regulations were discussed with Staff 1 (ED) and Staff 3. The staff acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 11 and 12) had documentation of first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Review of the facility's training records on 01/31/24 with Staff 3 (Business Office Manager) revealed the following: * Staff 11 (CG) and 12 (CG), hired on 09/22/23 and 11/20/23 respectively, lacked documentation of abdominal thrust/first aid training within 30 days of hire. On 01/31/24, the lack of documentation, staff training program and regulations were discussed with Staff 1 (ED) and Staff 3. The staff acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month, and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: Fire drill and fire and life safety training records, dated 06/2023 through 01/2024, were reviewed during the survey. The following deficiencies were identified: 1. The facility failed to conduct fire drills every other month. 2. Fire drills were conducted in 08/2023, 11/2023 and 01/2024 and lacked the following documentation: * Location of simulated fire origin; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Evacuation time period needed. 3. Fire and life safety instruction was not consistently provided to staff on alternate months. The requirements regarding fire drills, and fire and life safety instruction for staff on alternating months was reviewed with Staff 5 (Facility Services Director) on 01/31/24 and Staff 1 (ED) on 02/01/24. The staff acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month, and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: Fire drill and fire and life safety training records, dated 06/2023 through 01/2024, were reviewed during the survey. The following deficiencies were identified:”

“Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to: Fire and life safety records, dated 06/2023 through 01/2024, were reviewed during the survey and identified the facility lacked documented evidence of the following: * Fire and life safety training for residents, at least annually, included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building. The requirements regarding fire and life safety instruction for residents was reviewed with Staff 5 (Facility Services Director) on 01/31/24 and Staff 1 (ED) on 02/01/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to: Fire and life safety records, dated 06/2023 through 01/2024, were reviewed during the survey and identified the facility lacked documented evidence of the following: * Fire and life safety training for residents, at least annually, included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building. The requirements regarding fire and life safety instruction for residents was reviewed with Staff 5 (Facility Services Director) on 01/31/24 and Staff 1 (ED) on 02/01/24. They acknowledged the findings.”

“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 C 361 and C 372. 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 C 361 and C 372.”

“Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: Observations on 01/30/24 and 01/31/24 identified the following areas in need of cleaning or repair: 1. Handrails throughout the assisted living unit halls were in disrepair, including chips, gouges and splintered wood. 2. Flooring in the memory care unit dining room had black streaks and gouges. The areas needing cleaning and repair were reviewed with Staff 5 (Facility Services Director) on 01/31/24 and Staff 1 (ED) on 02/01/24. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: Observations on 01/30/24 and 01/31/24 identified the following areas in need of cleaning or repair:”

“Based on observation, interview and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. Findings include, but are not limited to: Refer to C361, C372, C420, C422 and C613. Based on observation, interview and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. Findings include, but are not limited to: Refer to C361, C372, C420, C422 and C613.”

“Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation for 4 of 4 newly hired staff (#s 8, 10, 11 and 12), pre-service dementia training completed for 2 of 3 newly hired staff (#s 10, 11 and 12), demonstrated competency completed in all required areas within 30 days of hire for 2 of 3 newly hired staff (#s 11 and 12), and a total of 16 hours of in-service training completed annually including six hours related to dementia care topics for 4 of 4 long-term direct care staff (#s 6, 7, 9 and 13). Findings include, but are not limited to: On 01/31/24, training records were reviewed with Staff 3 (Business Office Manager). The following deficiencies were identified. 1. Staff 8 (Housekeeping), Staff 10 (CG), Staff 11 (CG), and Staff 12 (CG), were hired on 12/12/23, 11/17/23, 09/22/23, and 11/20/23 respectively. a. Staff 8, Staff 10, Staff 11 and Staff 12 lacked pre-service orientation documentation in the following areas: * Infectious Disease Prevention. Additionally, Staff 11 lacked documentation of the following: * Fire safety and emergency procedures. b. Staff  10, 11, and 12 lacked pre-service dementia training in multiple required areas. c. Staff 11 and 12 lacked documented evidence of competency demonstration in multiple required areas within 30 days of hire. 2. Staff 6 (CG), Staff 7 (MT), Staff 9 (CG) and Staff 13 (MT), all hired on 05/01/22, lacked documented evidence of completion of 16 hours of annual in-service training which included at least six hours of dementia care training, reviewed by the anniversary date of the staff's hire. The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (ED) and Staff 3 on 01/31/24. The staff acknowledged the findings. Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation for 4 of 4 newly hired staff (#s 8, 10, 11 and 12), pre-service dementia training completed for 2 of 3 newly hired staff (#s 10, 11 and 12), demonstrated competency completed in all required areas within 30 days of hire for 2 of 3 newly hired staff (#s 11 and 12), and a total of 16 hours of in-service training completed annually including six hours related to dementia care topics for 4 of 4 long-term direct care staff (#s 6, 7, 9 and 13). Findings include, but are not limited to: On 01/31/24, training records were reviewed with Staff 3 (Business Office Manager). The following deficiencies were identified.”

“Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C260, C305 and C310. Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C260, C305 and C310. Refer to (C260, C310) Refer to (C260, C310) There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 2 of 2 sampled memory care residents (#s 4 and 5), whose records were reviewed. Findings include, but are not limited to: Residents 4 and 5's service plans, "Life Stories", and evaluations were reviewed. There was some historical personal information included, but the records lacked documented evidence the facility had fully evaluated the residents including: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no documented evidence of specific activity plans which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities. The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (ED) and Staff 14 (Activities Director) on 02/01/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 2 of 2 sampled memory care residents (#s 4 and 5), whose records were reviewed. Findings include, but are not limited to: Residents 4 and 5's service plans, "Life Stories", and evaluations were reviewed. There was some historical personal information included, but the records lacked documented evidence the facility had fully evaluated the residents including: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no documented evidence of specific activity plans which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities. The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (ED) and Staff 14 (Activities Director) on 02/01/24. They acknowledged the findings.”