Sunnyside Meadows.

“Based on observation, interview, and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 4 sampled residents (#s 1, 2, and 3) whose ABST records were reviewed. Findings include, but are not limited to: Resident 1, 2, and 3’s service plans, Interim Service Plans (ISPs), and corresponding ABST individual minutes were reviewed. The residents were observed, and interviews were conducted with staff. The residents’ ABST evaluated care times and care elements were found to not be reflective in one or more of the following areas: * Bowel and bladder management; * Dressing; * Personal hygiene; * Grooming; * Safety checks; * Ambulation; * Repositioning; * Assisting with leisure activities; * Communication; * Transfers; and * Call lights. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (LPN), Staff 26 (Regional RN), and Staff 27 (Regional RN) on 11/13/25. They acknowledged the findings. ABST was reviewed and updated for Resident #1, #2, and #3 at the time of the survey to correct noted discrepancies. ABST has been assigned to the LPN for review, as the LPN has more direct knowledge of the residents’ needs, which will help increase the accuracy of information in the ABST tool. ABST reviews are completed as part of service plan and evaluation updates, as well as whenever there are significant changes in a resident’s condition. Executive Director will audit the ABST tool weekly for the first 30 days and every two weeks thereafter. A sample of residents will be reviewed to ensure that the care being provided on the floor aligns with what is documented in the service plan and ABST. Executive Director is responsible for ensuring that all corrections are completed and monitored.”

“Based on observation, interview, and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 4 sampled residents (#s 1, 2, and 3) whose ABST records were reviewed. Findings include, but are not limited to: Resident 1, 2, and 3’s service plans, Interim Service Plans (ISPs), and corresponding ABST individual minutes were reviewed. The residents were observed, and interviews were conducted with staff. The residents’ ABST evaluated care times and care elements were found to not be reflective in one or more of the following areas: * Bowel and bladder management; * Dressing; * Personal hygiene; * Grooming; * Safety checks; * Ambulation; * Repositioning; * Assisting with leisure activities; * Communication; * Transfers; and * Call lights. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (LPN), Staff 26 (Regional RN), and Staff 27 (Regional RN) on 11/13/25. They acknowledged the findings. ABST was reviewed and updated for Resident #1, #2, and #3 at the time of the survey to correct noted discrepancies. ABST has been assigned to the LPN for review, as the LPN has more direct knowledge of the residents’ needs, which will help increase the accuracy of information in the ABST tool. ABST reviews are completed as part of service plan and evaluation updates, as well as whenever there are significant changes in a resident’s condition. Executive Director will audit the ABST tool weekly for the first 30 days and every two weeks thereafter. A sample of residents will be reviewed to ensure that the care being provided on the floor aligns with what is documented in the service plan and ABST. Executive Director is responsible for ensuring that all corrections are completed and monitored.”

“Based on interview and record review, conducted during a site visit on 09/18/24, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to: During an interview on 09/18/24, a staff member stated the facility had been staffed short of the facility's posted staffing plan on a few evening shifts in August 2024 and September 2024. A review of the facility's posted staffing plans dated 08/01/24 and 09/01/24 both indicated a need for nine care staff on evening shift. A review of facility time cards revealed only eight staff working on evening shift on 08/24/24, 08/26/24 and 09/15/24. The facility failed to fully implement an ABST. The findings were reviewed with and Acknowledged by Staff 1 (Administrator), Staff  6 (Operations Specialist, Seasons Management), Staff 7 (Director of Operations, Seasons Management), Staff 8 (Vice President of Clinical Operations, Seasons Management ), Staff 9 (Chief Operations Officer), Seasons Management) and Staff 10 (Facility Owner) by phone on 09/19/24. Based on interview and record review, conducted during a site visit on 09/18/24, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to: During an interview on 09/18/24, a staff member stated the facility had been staffed short of the facility's posted staffing plan on a few evening shifts in August 2024 and September 2024. A review of the facility's posted staffing plans dated 08/01/24 and 09/01/24 both indicated a need for nine care staff on evening shift. A review of facility time cards revealed only eight staff working on evening shift on 08/24/24, 08/26/24 and 09/15/24. The facility failed to fully implement an ABST. The findings were reviewed with and Acknowledged by Staff 1 (Administrator), Staff  6 (Operations Specialist, Seasons Management), Staff 7 (Director of Operations, Seasons Management), Staff 8 (Vice President of Clinical Operations, Seasons Management ), Staff 9 (Chief Operations Officer), Seasons Management) and Staff 10 (Facility Owner) by phone on 09/19/24.”

“Based on observation, interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse for 1 of 1 sampled resident (#2). Findings include, but are not limited to: During the site visit on 05/13/24, the Compliance Specialist was alerted to a situation in which Resident 2 was seated in a wheelchair and experienced an unwitnessed fall. On 05/13/24 a wheelchair was observed in Resident 2's room with a note that stated the wheelchair was for transport only. The use of a wheelchair was not mentioned in Resident 2's service plan dated 05/07/24. During an interview by phone on 05/15/24, Staff 1 (Administrator), Staff 10 (RN) and Staff 22 (Consultant) were asked if the incident was investigated by the facility and how abuse or neglect was ruled out. Staff 1 explained that he assessed the resident and that the resident had been observed less than 10 minutes prior to being discovered. The CS stated the service plan did not mention the use of a wheelchair and asked for clarification on its use. Staff 22 stated abuse or neglect could not have been ruled out if the service plan was not being followed or was not reflective of Resident 2's needs. A review of a fall investigation initiated on 05/11/24 confirmed Resident 2 had a fall after sitting in an unlocked wheelchair. The incident was reported by the facility to APS on 05/15/24 at the direction of the CS. The findings were reviewed with and acknowledged by Staff 1, Staff 10, and Staff 22 by phone on 05/15/24. The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse. Verbal plan of correction: Consultant was in the facility weekly, reviewed incidences from the previous week and working with clinical staff for follow-up. Based on observation, interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse for 1 of 1 sampled resident (#2). Findings include, but are not limited to: During the site visit on 05/13/24, the Compliance Specialist was alerted to a situation in which Resident 2 was seated in a wheelchair and experienced an unwitnessed fall. On 05/13/24 a wheelchair was observed in Resident 2's room with a note that stated the wheelchair was for transport only. The use of a wheelchair was not mentioned in Resident 2's service plan dated 05/07/24. During an interview by phone on 05/15/24, Staff 1 (Administrator), Staff 10 (RN) and Staff 22 (Consultant) were asked if the incident was investigated by the facility and how abuse or neglect was ruled out. Staff 1 explained that he assessed the resident and that the resident had been observed less than 10 minutes prior to being discovered. The CS stated the service plan did not mention the use of a wheelchair and asked for clarification on its use. Staff 22 stated abuse or neglect could not have been ruled out if the service plan was not being followed or was not reflective of Resident 2's needs. A review of a fall investigation initiated on 05/11/24 confirmed Resident 2 had a fall after sitting in an unlocked wheelchair. The incident was reported by the facility to APS on 05/15/24 at the direction of the CS. The findings were reviewed with and acknowledged by Staff 1, Staff 10, and Staff 22 by phone on 05/15/24. The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse. Verbal plan of correction: Consultant was in the facility weekly, reviewed incidences from the previous week and working with clinical staff for follow-up.”

“Based on observation and interview, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to ensure the service plans were readily available to staff and provide clear direction regarding the delivery of services for 1 of 1 sampled resident (#5). Findings include, but are not limited to: During the site visit on 05/13/24, Resident 5's service plan available to staff on the floor only contained even pages and was incomplete. During an interview on 05/13/24, Staff 1 (Administrator) stated he had printed a complete service plan and asked staff to put it in the binder the week prior. He further stated he would ensure a complete service plan was added to the binder immediately. Upon return to the facility on of 05/14/24, Resident 5's service plan was complete and available to staff. The findings were reviewed with and acknowledged by Staff 1, Staff 10 (RN), and Staff 22 (Consultant) by phone on 05/15/24. The facility failed to make service plans readily available to staff. Based on observation, interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to ensure the service plan was reflective of resident needs and implemented by staff for 1 of 4 sampled residents (#2). Findings include, but are not limited to: Inconsistencies were identified between Resident 2's service plan dated 05/07/24, observations of care and interviews with staff in the following areas: *Ambulation; and *Use of a wheelchair During an observation on 05/14/24, Staff 7 (CG) was observed attempting to help Resident 2 stand. Staff 7 stated loudly s/he wasn't sure what to do. Staff 8 (CG) went to Resident 2 and Staff 7 and assisted Resident 2 to standing and assisted him/her in walking to the dining area with two handed assistance. Resident 2's service plan noted Resident 2 "requires assistance from one care team member with mobility for safety per PT on 11/10/23. [Resident 2] is able to walk independently but needs guidance with [his/her] escorts due to poor safety awareness." On 05/13/24 a wheelchair was observed in Resident 2's room with a note that stated the wheelchair was for transport only. A review of a fall investigation initiated on 05/11/24 revealed Resident 2 had a fall after sitting in an unlocked wheelchair. The use of a wheelchair was not mentioned in Resident 2's service plan. During an interview on 05/14/24, Staff 8 stated Resident 2 needed a lot of cueing. Staff 8 further stated Staff 7 was a newer CG, and needed to be shown how to help Resident 2. Staff help Resident 2 walk to/from all meals and activities. The facility failed to ensure the service plan was reflective of resident needs and implemented by staff. The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 10 (RN), and Staff 22 (Consultant) by phone on 05/15/24. Verbal plan of correction:  Service plans will be reviewed by end of day 05/15/24 and ongoing in clinical meeting and weekly. Based on observation and interview, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to ensure the service plans were readily available to staff and provide clear direction regarding the delivery of services for 1 of 1 sampled resident (#5). Findings include, but are not limited to: During the site visit on 05/13/24, Resident 5's service plan available to staff on the floor only contained even pages and was incomplete. During an interview on 05/13/24, Staff 1 (Administrator) stated he had printed a complete service plan and asked staff to put it in the binder the week prior. He further stated he would ensure a complete service plan was added to the binder immediately. Upon return to the facility on of 05/14/24, Resident 5's service plan was complete and available to staff. The findings were reviewed with and acknowledged by Staff 1, Staff 10 (RN), and Staff 22 (Consultant) by phone on 05/15/24. The facility failed to make service plans readily available to staff. Based on observation, interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to ensure the service plan was reflective of resident needs and implemented by staff for 1 of 4 sampled residents (#2). Findings include, but are not limited to: Inconsistencies were identified between Resident 2's service plan dated 05/07/24, observations of care and interviews with staff in the following areas: *Ambulation; and *Use of a wheelchair During an observation on 05/14/24, Staff 7 (CG) was observed attempting to help Resident 2 stand. Staff 7 stated loudly s/he wasn't sure what to do. Staff 8 (CG) went to Resident 2 and Staff 7 and assisted Resident 2 to standing and assisted him/her in walking to the dining area with two handed assistance. Resident 2's service plan noted Resident 2 "requires assistance from one care team member with mobility for safety per PT on 11/10/23. [Resident 2] is able to walk independently but needs guidance with [his/her] escorts due to poor safety awareness." On 05/13/24 a wheelchair was observed in Resident 2's room with a note that stated the wheelchair was for transport only. A review of a fall investigation initiated on 05/11/24 revealed Resident 2 had a fall after sitting in an unlocked wheelchair. The use of a wheelchair was not mentioned in Resident 2's service plan. During an interview on 05/14/24, Staff 8 stated Resident 2 needed a lot of cueing. Staff 8 further stated Staff 7 was a newer CG, and needed to be shown how to help Resident 2. Staff help Resident 2 walk to/from all meals and activities. The facility failed to ensure the service plan was reflective of resident needs and implemented by staff. The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 10 (RN), and Staff 22 (Consultant) by phone on 05/15/24. Verbal plan of correction:  Service plans will be reviewed by end of day 05/15/24 and ongoing in clinical meeting and weekly.”

“Based on interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to ensure a resident monitoring and reporting system was implemented 24-hours a day for 1 of 1 sampled resident (#2). Findings include, but are not limited to: A review of Resident 2's progress notes dated 04/03/24 through 05/13/24 and Temporary Service Plans dated 04/06/24 through 04/30/24 revealed: *On 04/18/24 Resident 2's PCP was contacted related to concern for a Urinary Tract Infection and genital herpes. *On 04/20/24 Resident 2 started Miralax for constipation. There was no documented evidence of written communication of Resident 2's change of condition, and any required interventions, for direct care staff on each shift. During an interview on 05/15/24, Staff 1 (Administrator) stated he was alerted in the facility's stand-up meeting that staff were trying to get a urinalysis for Resident 2 on 04/18/24 because they "felt s/he was not his/herself". Staff 1 further stated that should have been documented by the MT, but was not and Resident 2 was not put on alert for monitoring the change of condition. The findings were reviewed with and acknowledged by Staff 1, Staff 10 (RN), and Staff 22 (Consultant) by phone on 05/15/24. The facility failed to ensure a resident monitoring and reporting system was implemented 24-hours a day. Verbal plan of Correction: In clinical meeting the facility would review TSPs, alert charting and missed medications daily. Based on interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to ensure a resident monitoring and reporting system was implemented 24-hours a day for 1 of 1 sampled resident (#2). Findings include, but are not limited to: A review of Resident 2's progress notes dated 04/03/24 through 05/13/24 and Temporary Service Plans dated 04/06/24 through 04/30/24 revealed: *On 04/18/24 Resident 2's PCP was contacted related to concern for a Urinary Tract Infection and genital herpes. *On 04/20/24 Resident 2 started Miralax for constipation. There was no documented evidence of written communication of Resident 2's change of condition, and any required interventions, for direct care staff on each shift. During an interview on 05/15/24, Staff 1 (Administrator) stated he was alerted in the facility's stand-up meeting that staff were trying to get a urinalysis for Resident 2 on 04/18/24 because they "felt s/he was not his/herself". Staff 1 further stated that should have been documented by the MT, but was not and Resident 2 was not put on alert for monitoring the change of condition. The findings were reviewed with and acknowledged by Staff 1, Staff 10 (RN), and Staff 22 (Consultant) by phone on 05/15/24. The facility failed to ensure a resident monitoring and reporting system was implemented 24-hours a day. Verbal plan of Correction: In clinical meeting the facility would review TSPs, alert charting and missed medications daily.”

“Based on interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to cary out medication orders as prescribed for 1 of 1 sampled residents (#3). Findings include, but are not limited to: A review of Resident 3's signed physican orders dated 03/19/24 revealed an order for Levothryroid 100 mcg once daily. A review of Resident 3's MAR dated 03/01/24 through 03/31/24 revealed Resident 3 missed one dose of the medication on 03/21/24. The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 05/13/24 who confirmed the error occured. The facility failed to carry out medication orders as prescribed. Verbal plan of correction: MTs are now to be re-ordering medication 1-2 weeks in advance, depending on pharmacy. Administrator to provide training to MTs by end of 05/24/24 about re-ordering process and narcotics requiring new prescription from provider. Based on interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facillity failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of Resident 1's signed physician order dated 02/02/24 revealed an order for: Lorazepam (anxiety medication) 0.5 mg tablet take one tablet by mouth once a day. A review of Resident 1's MAR dated 02/01/24 through 02/29/24 revealed Resident 1 missed one dose of the medication on 02/03/24. The findings were reviewed with Staff 1 (Administrator) on 05/13/24 who confirmed the error occured. The facillity failed to carry out medication orders as prescribed. Verbal plan of correction: MTs are now to be re-ordering medication 1-2 weeks in advance, depending on pharmacy. Administrator to provide training to MTs by end of 05/24/24 about re-ordering process and narcotics requiring new prescription from provider. Based on interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to administer medications as prescribed for 1 of 1 samped resident (#4). Findings include, but are not limited to: A review of Resident 4's signed physician orders dated 11/12/23 revealed an order for: Donepezil (dementia medication) 6 mg tablet, take one tab by mouth once a day. A review of Resident 4's MAR dated 02/01/24 through 02/29/23 revealed Resident 4 missed one dose of the medication on 02/12/24. The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 05/13/24, who confirmed the error occured. The facility failed to administer medications as prescribed. Verbal plan of correction: MTs are now to be re-ordering medication 1-2 weeks in advance, depending on pharmacy. Administrator to provide training to MTs by end of 05/24/24 about re-ordering process and narcotics requiring new prescription from provider. Based on interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to cary out medication orders as prescribed for 1 of 1 sampled residents (#3). Findings include, but are not limited to: A review of Resident 3's signed physican orders dated 03/19/24 revealed an order for Levothryroid 100 mcg once daily. A review of Resident 3's MAR dated 03/01/24 through 03/31/24 revealed Resident 3 missed one dose of the medication on 03/21/24. The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 05/13/24 who confirmed the error occured. The facility failed to carry out medication orders as prescribed. Verbal plan of correction: MTs are now to be re-ordering medication 1-2 weeks in advance, depending on pharmacy. Administrator to provide training to MTs by end of 05/24/24 about re-ordering process and narcotics requiring new prescription from provider. Based on interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facillity failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of Resident 1's signed physician order dated 02/02/24 revealed an order for: Lorazepam (anxiety medication) 0.5 mg tablet take one tablet by mouth once a day. A review of Resident 1's MAR dated 02/01/24 through 02/29/24 revealed Resident 1 missed one dose of the medication on 02/03/24. The findings were reviewed with Staff 1 (Administrator) on 05/13/24 who confirmed the error occured. The facillity failed to carry out medication orders as prescribed. Verbal plan of correction: MTs are now to be re-ordering medication 1-2 weeks in advance, depending on pharmacy. Administrator to provide training to MTs by end of 05/24/24 about re-ordering process and narcotics requiring new prescription from provider. Based on interview and record review, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to administer medications as prescribed for 1 of 1 samped resident (#4). Findings include, but are not limited to: A review of Resident 4's signed physician orders dated 11/12/23 revealed an order for: Donepezil (dementia medication) 6 mg tablet, take one tab by mouth once a day. A review of Resident 4's MAR dated 02/01/24 through 02/29/23 revealed Resident 4 missed one dose of the medication on 02/12/24. The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 05/13/24, who confirmed the error occured. The facility failed to administer medications as prescribed. Verbal plan of correction: MTs are now to be re-ordering medication 1-2 weeks in advance, depending on pharmacy. Administrator to provide training to MTs by end of 05/24/24 about re-ordering process and narcotics requiring new prescription from provider.”

“Based on observation and interview, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to keep all interior materials and surfaces clean, and in good repair. Findings include, but are not limited to: At approximately 11:39 am on 05/13/24, Staff 3 (CG) was observed assisting Resident 2 in ambulation to a table in the dining area. During the observation, the rubber threshold between a carpeted area and a linoleum area was loose from the floor and presented a tripping hazard to Resident 2. During an interview on 05/13/24, Staff 1 (Administrator) stated a maintenance person would work to fix that by end of day. Upon return to the facility on 05/14/24, the section of threshold that was previously loose was adhered to the floor. The facility failed to keep all interior materials and surfaces clean, and in good repair. The findings were reviewed with and acknowledged by Staff 1, Staff 10 (RN), and Staff 22 (Consultant) by phone on 05/15/24. Based on observation and interview, conducted during a site visit on 05/13/24 and 05/14/24, it was confirmed the facility failed to keep all interior materials and surfaces clean, and in good repair. Findings include, but are not limited to: At approximately 11:39 am on 05/13/24, Staff 3 (CG) was observed assisting Resident 2 in ambulation to a table in the dining area. During the observation, the rubber threshold between a carpeted area and a linoleum area was loose from the floor and presented a tripping hazard to Resident 2. During an interview on 05/13/24, Staff 1 (Administrator) stated a maintenance person would work to fix that by end of day. Upon return to the facility on 05/14/24, the section of threshold that was previously loose was adhered to the floor. The facility failed to keep all interior materials and surfaces clean, and in good repair. The findings were reviewed with and acknowledged by Staff 1, Staff 10 (RN), and Staff 22 (Consultant) by phone on 05/15/24.”

“Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. Z142 See above POC. Culinary Manager, Maintenance director, Executive Director or designee will be responsible for the compliance. February 26, 2024 Z142 See above POC. Culinary Manager, Maintenance director, Executive Director or designee will be responsible for the compliance. February 26, 2024 There are no detail notes for this visit.”

“The findings of the kitchen inspection, conducted 12/28/23, 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 kitchen inspection, conducted 12/28/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the first revisit to the kitchen inspection of 12/28/23, conducted 03/13/24, 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. The findings of the first revisit to the kitchen inspection of 12/28/23, conducted 03/13/24, 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 kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 12/28/23 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas: * The hood vents above stove/grill had accumulation of  dust/grease; * The ceiling vents near the walk in refrigerator and freezer had accumulation of dust and the wall area near the ceiling in same location had dust build up; and * The back splash behind the spray sink area had black matter accumulation. Additional observations noted dishwashing staff was not washing hands between clean and dirty tasks. One staff was observed not using hair restraint. The findings were discussed with Staff 1 (Person in Charge - Cook) and Staff 2 (Executive Administrator) on 12/28/23. The findings were acknowledged. 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 12/28/23 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas: * The hood vents above stove/grill had accumulation of  dust/grease; * The ceiling vents near the walk in refrigerator and freezer had accumulation of dust and the wall area near the ceiling in same location had dust build up; and * The back splash behind the spray sink area had black matter accumulation. Additional observations noted dishwashing staff was not washing hands between clean and dirty tasks. One staff was observed not using hair restraint. The findings were discussed with Staff 1 (Person in Charge - Cook) and Staff 2 (Executive Administrator) on 12/28/23. The findings were acknowledged. C 240 The Culinary Department staff will maintain sanitation of all areas of the kitchen. A checklist has been developed the culinary manager outlining daily, weekly, monthly and quarterly sanitation practices to be completed by culinary staff. Checklist will be maintained in a binder in CD office. Culinary Manager will perform quality checks. Once a quarter an outside provide will be assigned to provide a deep clean of the hood. Culinary Manager will provide a schedule and post in the kitchen for staff to be aware of the cleaning schedule of the hood vents. The ceiling vents will be on a daily or weekly basis schedule. Maintenance Director and the Culinary Manger will coordinate and provide a best practice for staff to notified Maintenance Director back splash has black matter accumulation. Maintenance Director will have a monthly PM checks to prevent black matter to accumulate and will have a checklist for the Culinary Manager and Executive Director monthly. Infection Control and sanitation training will be provided to the culinary staff and be completed by February 15, 2024. C 240 The Culinary Department staff will maintain sanitation of all areas of the kitchen. A checklist has been developed the culinary manager outlining daily, weekly, monthly and quarterly sanitation practices to be completed by culinary staff. Checklist will be maintained in a binder in CD office. Culinary Manager will perform quality checks. Once a quarter an outside provide will be assigned to provide a deep clean of the hood. Culinary Manager will provide a schedule and post in the kitchen for staff to be aware of the cleaning schedule of the hood vents. The ceiling vents will be on a daily or weekly basis schedule. Maintenance Director and the Culinary Manger will coordinate and provide a best practice for staff to notified Maintenance Director back splash has black matter accumulation. Maintenance Director will have a monthly PM checks to prevent black matter to accumulate and will have a checklist for the Culinary Manager and Executive Director monthly. Infection Control and sanitation training will be provided to the culinary staff and be completed by February 15, 2024. There are no detail notes for this visit.”

“The findings of the on-site investigation, conducted 12/18/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day The findings of the on-site investigation, conducted 12/18/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day”

“Based on interview and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to report a physical injury of unknown cause to the local Department office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse for 1 of 1 sampled resident (#3). Findings include, but are not limited to: An incident report dated 10/09/23 revealed Resident 3 was found on the floor with a small pool of blood noted that morning. The incident report noted the event was reported to APS on 11/20/23. There was no evidence that the facility ruled out abuse or neglect. During an interview on 12/18/23, Staff 9 (Consultant) stated the incident was discovered by reviewing incomplete incident reports in their daily clinical meeting in November 2023. The findings of the investigation were reviewed with and acknowledged by Staff 9 and Staff 10 (Administrator) on 12/18/23. The facility failed to report a physical injury of unknown cause to the local Department office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. Verbal plan of correction: The interdisciplinary team will be going through all incident reports 5 days/week and ensuring completion. They review 24 hour and 72 hour progress notes in clinical meetings. Their consultant had contacted PCC (Electronic Medical Record) to auto-click to include all progress notes on 24 hour report so all charting pops up, but had not yet been resolved. The facility just re-trained staff last week on abuse reporting and investigation guidelines. Training with IDT team on abuse reporting was conducted 12/06/23. Weekend staff should report to Administrator or report to APS. Administrator would come in on the weekend to evaluate the resident and situation if needed on a Saturday. RCC is at the facility on Sundays to assist with APS reporting if needed. Based on interview and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to report a physical injury of unknown cause to the local Department office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse for 1 of 1 sampled resident (#3). Findings include, but are not limited to: An incident report dated 10/09/23 revealed Resident 3 was found on the floor with a small pool of blood noted that morning. The incident report noted the event was reported to APS on 11/20/23. There was no evidence that the facility ruled out abuse or neglect. During an interview on 12/18/23, Staff 9 (Consultant) stated the incident was discovered by reviewing incomplete incident reports in their daily clinical meeting in November 2023. The findings of the investigation were reviewed with and acknowledged by Staff 9 and Staff 10 (Administrator) on 12/18/23. The facility failed to report a physical injury of unknown cause to the local Department office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. Verbal plan of correction: The interdisciplinary team will be going through all incident reports 5 days/week and ensuring completion. They review 24 hour and 72 hour progress notes in clinical meetings. Their consultant had contacted PCC (Electronic Medical Record) to auto-click to include all progress notes on 24 hour report so all charting pops up, but had not yet been resolved. The facility just re-trained staff last week on abuse reporting and investigation guidelines. Training with IDT team on abuse reporting was conducted 12/06/23. Weekend staff should report to Administrator or report to APS. Administrator would come in on the weekend to evaluate the resident and situation if needed on a Saturday. RCC is at the facility on Sundays to assist with APS reporting if needed.”

“Based on observation, interview and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to carry out medication orders as prescribed for 4 of 4 sampled residents (#s 1, 2, 4 and 5). Findings include, but are not limited to: 1. Resident 1's 12/01/23- 12/18/23 MAR noted an order for Tramadol (pain reliever) 50mg Tab take one tablet by mouth every day. On 12/15/23 the medication was noted as given on the MAR. The corresponding narcotic log and the medication card was observed and reviewed and there was no evidence the medication was given on 12/15/23. During a phone interview on 12/18/23 Staff 14 (MT) became agitated and stated s/he couldn't remember if s/he had given it, but thinks s/he remembered giving it, but then later stated "I guess I forgot to give it." Staff 14 further stated that sometimes s/he initialed and dated next to the narcotics s/he pops on the cards, but sometimes s/he doesn't. 2. A review of Resident 2's chart and 12/01/23 through 12/18/23 MAR identified one occasion when morphine sulfate 20mg/ml was administered per the narcotics log on 12/09/23, and not recorded as administered on the MAR. The current physician orders in the resident's record, dated 10/18/23, indicated to "notify ElderPlace for change of condition or PRIOR to using." In an interview on 12/18/23, via phone call with Staff 14 confirmed s/he had administered Resident 2's liquid morphine recently after asking resident if s/he was having hip pain and resident grumbled in response. Staff 14 stated s/he had not contacted ElderPlace and could not remember if s/he charted in the MAR. 3. A review of Resident 4's October and November 2023 MAR noted an order for Lexothyroxine Sodium Oral Tablet 112 MCG 1 Tablet by mouth one time a day every Monday for hypothyroid beginning 06/29/23. Resident 4's October 2023 and November 2023 MAR indicated the medication was given as ordered each Monday. Packing slips or proof the medication was received prior to 11/15/23 was requested but was not available. During an interview on 12/18/23, Staff 1 and Staff 2 (MTs) stated the facility did not have the right dose of Resident 4's Monday dose of levothyroxine for months so the MTs were just giving Resident 4 the regular daily dose and marking it as the higher dose. Staff 1 further stated s/he had notified day shift MTs and management of the issue. Staff 1 and Staff 2 stated the facility received the correct dose for the medication in the last few weeks. 4. A review of Resident 5's chart and 10/01/23 through 12/18/23 MAR's indicated the following: * 12 instances of Nizoral A-D shampoo not being administer due to "not residents shower day."; * 2 instances of Trazodone not administered due to medication not available; * 4 instances of Amiodarone not administered due to medication not available; * 4 instances of Risperidone not administered due to medication not available; * 2 instances of Simvastatin not administered due to medication not available; * 2 instances of Brimonidine Tartrate Ophthalmic Solution not found in cart and 6 instances of medication not administered due to not available; * 3 instances of Oxycodone not administered due to medication not available; and * On 10/16/23 all evening medications were missed (13 medications). The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 (Administrator) on 12/18/23. The facility failed to carry out medication orders as prescribed. Verbal Plan of Correction: Staff 9 and Staff 10 will audit the narcotics which will be completed by 12/19/23. Staff 9 is working with MAR service provider to put in time parameters for medication administration. There will be an in-service for all med techs on the rights of medication administration. The consulting RN is beginning the process of reviewing all physician orders and ensuring appropriate medication in stock and ordered. Administrator to audit competencies for all MTs by 12/12/23. Competencies for individuals will be verified on the staff member's next scheduled day. Staff 14 will be removed from the medication cart and counseling provided to determine employment status moving forward. Based on observation, interview and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to carry out medication orders as prescribed for 4 of 4 sampled residents (#s 1, 2, 4 and 5). Findings include, but are not limited to:”

“Based on observation, interview and record review it, conducted during a site visit on 12/18/23, it was determined the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: The facility's posted staffing plan was observed and reviewed on 12/18/23 which included the need for the following staff: Day shift: 2 MTs, 6 CGs Evening shift: 2 MTs, 6 CGs During interview, Staff 10 (Administrator) stated their posted staffing plan had not increased since she started in October 2023 as the facility had a condition imposed prohibiting new move-ins. A review of time cards for 11/20/23 noted a total of six care staff (MTs and CGs) worked on day and evening shift. During interview, Staff 10 stated the facility must have had call outs on 11/20/23 that led to being short-staffed. The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 on 12/18/23. The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Verbal plan of correction: The facility was utilizing agency staff and will complete a head count of staff available each shift. They are actively hiring for all shifts and offering referral bonuses. Based on observation, interview and record review, conducted during a site visit on 12/18/23, it was determined the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: The facility's posted staffing plan was observed and reviewed on 12/18/23 which included the need for the following staff on night shift: 2 MTs and 4 CGs. During interview, Staff 10 (Administrator) stated their posted staffing plan had not increased since she started in October 2023 as the facility had a condition imposed prohibiting new move-ins. A review of time cards for night shift on 10/21/23 as identified in the complaint revealed only three care staff (MTs and CGs) worked on the shift. During interview, Staff 10 (Administrator) stated the facility must have had call outs on 10/21/23 that led to being short-staffed. The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 on 12/18/23. The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Verbal plan of correction: The facility is utilizing agency staff and will complete a head count of staff available each shift. They are actively hiring for all shifts and offering referral bonuses. Based on observation, interview and record review it, conducted during a site visit on 12/18/23, it was determined the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: The facility's posted staffing plan was observed and reviewed on 12/18/23 which included the need for the following staff: Day shift: 2 MTs, 6 CGs Evening shift: 2 MTs, 6 CGs During interview, Staff 10 (Administrator) stated their posted staffing plan had not increased since she started in October 2023 as the facility had a condition imposed prohibiting new move-ins. A review of time cards for 11/20/23 noted a total of six care staff (MTs and CGs) worked on day and evening shift. During interview, Staff 10 stated the facility must have had call outs on 11/20/23 that led to being short-staffed. The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 on 12/18/23. The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Verbal plan of correction: The facility was utilizing agency staff and will complete a head count of staff available each shift. They are actively hiring for all shifts and offering referral bonuses. Based on observation, interview and record review, conducted during a site visit on 12/18/23, it was determined the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: The facility's posted staffing plan was observed and reviewed on 12/18/23 which included the need for the following staff on night shift: 2 MTs and 4 CGs. During interview, Staff 10 (Administrator) stated their posted staffing plan had not increased since she started in October 2023 as the facility had a condition imposed prohibiting new move-ins. A review of time cards for night shift on 10/21/23 as identified in the complaint revealed only three care staff (MTs and CGs) worked on the shift. During interview, Staff 10 (Administrator) stated the facility must have had call outs on 10/21/23 that led to being short-staffed. The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 on 12/18/23. The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Verbal plan of correction: The facility is utilizing agency staff and will complete a head count of staff available each shift. They are actively hiring for all shifts and offering referral bonuses.”

“Based on interview and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to documents that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 1 of 3 sampled MTs (#14). Findings include, but are not limited to: Staff 14's (MT) training records were reviewed. Staff 14 was hired on 10/24/23 and medication pass competencies checklist were signed by Staff 14 and his/her trainer on 11/21/23 indicating Staff 14 had received instruction on the competencies. There was no signature indicating the competencies were observed at a minimum of one medication pass or that Staff 14 had given medications under direct supervision of the trainer. A review of resident records revealed Staff 14 began documenting in narcotic logs and MARs as a MT as early as 11/09/23. The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 (Administrator) on 12/18/23. The facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised. Verbal plan of correction: Administrator to audit competencies for all MTs by 12/12/23. Competencies for individuals will be verified on the staff member's next scheduled day. Staff 14 will be removed from the medication cart and counseling provided to determine employment status moving forward. Based on interview and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to documents that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 1 of 3 sampled MTs (#14). Findings include, but are not limited to: Staff 14's (MT) training records were reviewed. Staff 14 was hired on 10/24/23 and medication pass competencies checklist were signed by Staff 14 and his/her trainer on 11/21/23 indicating Staff 14 had received instruction on the competencies. There was no signature indicating the competencies were observed at a minimum of one medication pass or that Staff 14 had given medications under direct supervision of the trainer. A review of resident records revealed Staff 14 began documenting in narcotic logs and MARs as a MT as early as 11/09/23. The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 (Administrator) on 12/18/23. The facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised. Verbal plan of correction: Administrator to audit competencies for all MTs by 12/12/23. Competencies for individuals will be verified on the staff member's next scheduled day. Staff 14 will be removed from the medication cart and counseling provided to determine employment status moving forward.”

“Based on interview and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to provide records upon request to the department. Findings include, but are not limited to: In an email dated 11/27/23, Witness 1 (Department staff) stated s/he had requested documents in person on 11/20/23, sent a second request by email on 11/21/23, followed up by phone on 11/22/23 and received requested records on 11/27/23. Records submitted by Witness 1 confirmed an email was sent on 11/21/23 and records were not received until 11/27/23. During an interview on 12/18/23 Staff 10 (Administrator) stated moving forward they would ensure that any documents requested by department staff are provided prior to them leaving the facility. The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 on 12/18/23. The facility failed to provide records available upon request. Verbal plan of correction: Facility to provide requested documents to department prior to exit. Based on interview and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to provide records upon request to the department. Findings include, but are not limited to: In an email dated 11/27/23, Witness 1 (Department staff) stated s/he had requested documents in person on 11/20/23, sent a second request by email on 11/21/23, followed up by phone on 11/22/23 and received requested records on 11/27/23. Records submitted by Witness 1 confirmed an email was sent on 11/21/23 and records were not received until 11/27/23. During an interview on 12/18/23 Staff 10 (Administrator) stated moving forward they would ensure that any documents requested by department staff are provided prior to them leaving the facility. The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 on 12/18/23. The facility failed to provide records available upon request. Verbal plan of correction: Facility to provide requested documents to department prior to exit.”

“Based on observation and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to keep the inside of the facility free from unpleasant odors. Findings include, but are not limited to the following: During a walkthrough of the facility a strong, pervasive urine like odor was observed in the 300's hall of the facility near the entrance door and strongest near the kitchenette. A review of daily communication logs dated 12/14/23 indicated a resident near the location of the odor had been urinating on his/her bedroom floor and refused to wear a brief. The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 (Administrator). The facility failed to keep the interior of the facility free from unpleasant odors. Verbal Plan of Correction: Maintenance will locate the source of the urine odor and steam clean the floors, which will be completed by 12/22/23. Based on observation and record review, conducted during a site visit on 12/18/23, it was confirmed the facility failed to keep the inside of the facility free from unpleasant odors. Findings include, but are not limited to the following: During a walkthrough of the facility a strong, pervasive urine like odor was observed in the 300's hall of the facility near the entrance door and strongest near the kitchenette. A review of daily communication logs dated 12/14/23 indicated a resident near the location of the odor had been urinating on his/her bedroom floor and refused to wear a brief. The findings of the investigation were reviewed with and acknowledged by Staff 9 (Consultant) and Staff 10 (Administrator). The facility failed to keep the interior of the facility free from unpleasant odors. Verbal Plan of Correction: Maintenance will locate the source of the urine odor and steam clean the floors, which will be completed by 12/22/23.”