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.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, provided clear direction regarding the delivery of services, included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and services were implemented for 6 of 7 sampled residents (#s 2, 3, 4, 5, 6, and 8) whose service plans were reviewed. Resident 3, who required meal assistance, had a significant weight loss. Resident 6's service plan was not followed, and s/he sustained a left hip fracture and a head laceration. Resident 8 required up to three staff assistance for ADLs. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 01/2023 with diagnoses including dementia, insomnia, abnormal weight loss and was identified in the acuity interview as having a history of falls. a. On 08/25/23, the resident experienced a fall and sustained a left hip fracture and head laceration. A review of the resident's record, including the most recent service plan and Temporary Service Plans (TSPs), interviews and observations with staff and the resident were conducted between 09/05/23 and 09/11/23 and revealed the following information: The Individual Service Plan Report, dated 06/22/23, documented Resident 6 required one caregiver escort and assistance for toileting. A handwritten note under toileting indicated the resident was "full assist," but was not dated or initialed. In an interview on 09/06/23 at 3:20 pm, Staff 8 (Staffing Coordinator/MT) confirmed the resident required one staff person to assist at all times with toileting, and not to be left alone. Staff 8 further stated the service plan was not being followed as the resident was left standing alone at the time the resident fell. During an interview on 09/07/23 at 10:20 am, Staff 9 (MT/CG) reported that prior to the fall, Resident 6 was engaged with activities, and was using a wheelchair or a four wheeled walker for mobility. She reported since the left hip fracture, Resident 6 was bedbound, had fluctuating pain, and required one to two staff members for repositioning for comfort. Observations from 09/05/23 through 09/11/23 of Resident 6 revealed s/he was confined to the bed and relied on staff for grooming, dressing, medications, meal assistance, and incontinence care. The facility investigation, completed 08/25/23, indicated the resident was left standing alone in the bathroom for an unknown amount of time. The facility's failure to ensure implementation of services resulted in Resident 6 experiencing a fall and sustaining a left hip fracture and head laceration. On 09/08/23, the survey team requested an immediate plan of correction to address the lack of a reflective service plan with clear direction to the staff for Resident 6. The plan was provided by the facility and approved by the survey team on 09/08/23 at 6:23 pm, and the situation was abated. b. Resident 6's service plan was not reflective or did not provide clear direction to staff following areas: * Bathing; * Skin condition, including wounds; * Modified diet; * Incontinent care; * Assistive devices, including hospital bed and side rail; * Evacuation assistance; * Meal assistance, including 1:1 assistance; * Outside providers; * Falls; * Activities and assistance required to participate; and * Mobility and transfers, including repositioning. The need to ensure service plans were reflective, available to staff, provided clear direction regarding the delivery of services, and was implemented was discussed with Staff 1 (ED), Staff 5 (Contractor), and Staff 7 (RN Consultant). They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, provided clear direction regarding the delivery of services, included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and services were implemented for 6 of 7 sampled residents (#s 2, 3, 4, 5, 6, and 8) whose service plans were reviewed. Resident 3, who required meal assistance, had a significant weight loss. Resident 6's service plan was not followed, and s/he sustained a left hip fracture and a head laceration. Resident 8 required up to three staff assistance for ADLs. Findings include, but are not limited to:”

“The findings of the re-licensure survey, conducted 09/05/23 through 09/08/23 and 09/11/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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 Situations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas: OAR 411-054-0036 (1), (2), & (4) Service plans; OAR 411-057-0140 (1) Administration Responsibilities; OAR 411-057-0155 (3) Staff Training Requirements; and OAR 411-057-0160 (2b) Compliance with Rules - Health Care. The facility put immediate plans of correction in place during the survey and the situations were abated. The findings of the re-licensure survey, conducted 09/05/23 through 09/08/23 and 09/11/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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 Situations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas: OAR 411-054-0036 (1), (2), & (4) Service plans; OAR 411-057-0140 (1) Administration Responsibilities; OAR 411-057-0155 (3) Staff Training Requirements; and OAR 411-057-0160 (2b) Compliance with Rules - Health Care. The facility put immediate plans of correction in place during the survey and the situations were abated. The findings of the revisit to the re-licensure survey of 09/11/23, conducted 04/09/24 through 04/11/24, are documented in this report. The survey was conducted to determine compliance with 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 the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with H refer to the Home and Community Based Services Rules OARs 411 Division 004. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the revisit to the re-licensure survey of 09/11/23, conducted 04/09/24 through 04/11/24, are documented in this report. The survey was conducted to determine compliance with 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 the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with H refer to the Home and Community Based Services Rules OARs 411 Division 004. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the second re-visit to the re-licensure survey of 09/11/23, conducted 07/23/24 through 07/24/24, 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 OARs 411 Division 004 Home and Community Based Services Regulations. The findings of the second re-visit to the re-licensure survey of 09/11/23, conducted 07/23/24 through 07/24/24, 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 OARs 411 Division 004 Home and Community Based Services Regulations.”

“Based on observation and interview, it was determined the facility failed to ensure 1 of 1 sampled resident (#8) was treated with dignity and respect, and had a safe and homelike environment. Findings include, but are not limited to: Resident 8 moved into the MCC in 04/2023 with diagnoses including dementia with unspecified psychotic disturbance. Observations during the survey from 09/05/23 through 09/08/23, identified the following: On 09/07/23 at approximately 4:30 pm, the surveyor overheard a staff member raising her voice and repeating, "get out" three times. When the staff member noticed the surveyor watching the interaction between her and Resident 8, her tone changed to calm and friendly. At that point she stated to the resident, "Come on, it's dinner time, let's get ready for dinner." The resident then walked out of the room with the staff member. The need to ensure residents were treated with dignity and respect and had a safe and homelike environment was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23 at 10:30 am. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure 1 of 1 sampled resident (#8) was treated with dignity and respect, and had a safe and homelike environment. Findings include, but are not limited to: Resident 8 moved into the MCC in 04/2023 with diagnoses including dementia with unspecified psychotic disturbance. Observations during the survey from 09/05/23 through 09/08/23, identified the following: On 09/07/23 at approximately 4:30 pm, the surveyor overheard a staff member raising her voice and repeating, "get out" three times. When the staff member noticed the surveyor watching the interaction between her and Resident 8, her tone changed to calm and friendly. At that point she stated to the resident, "Come on, it's dinner time, let's get ready for dinner." The resident then walked out of the room with the staff member. The need to ensure residents were treated with dignity and respect and had a safe and homelike environment was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23 at 10:30 am. They acknowledged the findings. The outside consultant and the ED have reviewed the residents rights Document and made necessary changes. Resident 8 service plan will be reviewed and updated by the RCC or designee for more person centered approaches for redirection when needed. Staff member involved with resident 8 has been terminated . ED or designee will hold an All-Staff meeting on abuse neglect, dignity and resident's rights. Training meeting will be held annually and as needed by ED or designee on abuse and neglect, dignity and residents rights. The outside consultant and the ED have reviewed the residents rights Document and made necessary changes. Resident 8 service plan will be reviewed and updated by the RCC or designee for more person centered approaches for redirection when needed. Staff member involved with resident 8 has been terminated . ED or designee will hold an All-Staff meeting on abuse neglect, dignity and resident's rights. Training meeting will be held annually and as needed by ED or designee on abuse and neglect, dignity and residents rights. There are no detail notes for this visit.”

“Based on observation, interview and record review, it was determined the facility failed to report injures of unknown cause to the local SPD office as suspected abuse unless an immediate facility investigation reasonably concluded the injury was not the result of abuse, failed to immediately notify the local SPD office of any incident of abuse or suspected abuse, and failed to promptly investigate incidents and take measures necessary to protect residents and prevent reoccurrence of abuse, for 4 of 4 sampled residents (#s 2, 4, 6, and 7) reviewed for incidents which required investigations or reporting. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2023 with diagnoses including dementia and epilepsy. a. The resident had a signed physician order for 100 mgs of lacosamide (a narcotic), one tablet by mouth two times a day for seizure disorder related to epilepsy. The medication was scheduled for administration at 8:00 am and 8:00 pm. Resident 2's Controlled Substance Disposition logs and MARS, dated 06/01/23 through 09/05/23, were reviewed and revealed the following: * On 07/28/23, the MAR reflected the resident refused the medication but the medication had been signed out on the disposition log; and * On 08/22/23, the MAR reflected staff couldn't locate the medication but the medication had been signed out on the disposition log. There was no evidence the disposition log count had been corrected when the medication was not administered, or documentation to show the medication had been disposed of. On 09/06/23, Staff 1 (ED) confirmed she was unaware of the issue. The surveyor requested the facility to report the incident. On 09/06/23 at 3:46 pm, the surveyor received verification the facility reported the missing narcotics to the local SPD office. b. Progress notes dated 06/13/23 through 09/04/23, Temporary Service Plans (TSPs) dated 07/01/23 through 07/25/23, and incident reports were reviewed. The following resident to resident altercations were documented: * TSP dated 07/01/23 - "[Y]elling and grabbing peers hands. Pulling, pushing, and yelling;" * Progress note on 07/14/23 - two documented attempts to hit another resident in which the MT was able to intervene, then documented, "this time [Resident 2] must have tried to hit [the other resident] because [the other resident] has a scratch to [his/her] right arm;" * Progress note on 07/23/23 - "Resident on alert for an altercation with [another resident]," with no other information included to what occurred; and * Progress note on 07/25/23 - "noticed [Resident 2] hitting/smacking [another resident] who is wheelchair bound." On 09/07/23 at 8:30 am, Staff 1 (ED) confirmed none of the resident to resident altercations had been reported to the local SPD office. The surveyor requested the incidents be reported to the local office. Verification the facility reported the resident to resident altercations was received on 09/07/23. The need to ensure resident to resident altercations were immediately reported to the local SPD office was discussed with Staff 1, Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on observation, interview and record review, it was determined the facility failed to report injures of unknown cause to the local SPD office as suspected abuse unless an immediate facility investigation reasonably concluded the injury was not the result of abuse, failed to immediately notify the local SPD office of any incident of abuse or suspected abuse, and failed to promptly investigate incidents and take measures necessary to protect residents and prevent reoccurrence of abuse, for 4 of 4 sampled residents (#s 2, 4, 6, and 7) reviewed for incidents which required investigations or reporting. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in the move-in evaluation, 30 day evaluations were used to develop the resident's service plan, and quarterly evaluations were reflective of the resident's current physical health status for 3 of 6 sampled residents (#s 2, 3, and 5) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility on 06/13/23 with diagnoses including dementia. The "Admission" evaluation, dated 06/09/23 was reviewed and lacked the following required elements: * Customary routines relating to eating and bathing; * List of medications and PRN use; * Vital signs if indicated by diagnosis, health problems, or medications; * Personality including how the person copes with change or challenging situations; * Nutrition habits, fluid preferences; * List of treatments; * Complex medication regimen; and * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature. The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. 2. Resident 5 was admitted to the facility on 07/06/23 with diagnoses including dementia. The move-in evaluation lacked the following required elements: * Customary routines relating to eating and bathing; * List of medications and PRN use; * Vital signs if indicated by diagnosis, health problems, or medications; * Personality including how the person copes with change or challenging situations; * Pain including pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Nutrition habits, fluid preferences; * Recent losses; * 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 the move-in evaluation addressed all required elements was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in the move-in evaluation, 30 day evaluations were used to develop the resident's service plan, and quarterly evaluations were reflective of the resident's current physical health status for 3 of 6 sampled residents (#s 2, 3, and 5) whose evaluations were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident, for 3 of 4 sampled residents (#s 3, 6, and 7) whose quarterly service plans were reviewed. Findings include, but are not limited to: Residents 3, 6, and 7's most recent service plans lacked documented evidence that a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident, for 3 of 4 sampled residents (#s 3, 6, and 7) whose quarterly service plans were reviewed. Findings include, but are not limited to: Residents 3, 6, and 7's most recent service plans lacked documented evidence that a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Reident 6 has passed away. Resident 3 service plan will be reviewed and care conference held with service planning team. Resident 7 service plan will be reviewed and care conference held with service planning team. Outside consultant or designee will complete an Inservice with the service planning team. The RCC or designee will invite outside members of the service planning team such as the residents legal representative, if applicable any person who is the residents choice, physician, or other health practitioner, as well as the facility staff as outlined in the rule to the care conference, and if they decline documents as such in the residents EMR. Outside Consultant or designee will review 2 resident SP weekly to ensure that they were completed and care conference held with the service planning team. Outside Consultant or designee will bring the results of these audits to QAPI monthly for 3 months or until deficient practice has resolved. Reident 6 has passed away. Resident 3 service plan will be reviewed and care conference held with service planning team. Resident 7 service plan will be reviewed and care conference held with service planning team. Outside consultant or designee will complete an Inservice with the service planning team. The RCC or designee will invite outside members of the service planning team such as the residents legal representative, if applicable any person who is the residents choice, physician, or other health practitioner, as well as the facility staff as outlined in the rule to the care conference, and if they decline documents as such in the residents EMR. Outside Consultant or designee will review 2 resident SP weekly to ensure that they were completed and care conference held with the service planning team. Outside Consultant or designee will bring the results of these audits to QAPI monthly for 3 months or until deficient practice has resolved. There are no detail notes for this visit.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had significant changes of condition were evaluated, referred to the facility RN and service plans updated, failed to monitor and document what actions or interventions were needed for short-term changes of condition, including resident-specific instructions communicated to staff on each shift and made part of the resident's record with weekly progress noted through resolution for 5 of 5 sampled residents (#s 2, 3, 5, 6, and 7) who experienced changes of condition. Resident's 3 and 6 experienced severe weight loss. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2021 with diagnoses including dementia and a history of pubis fracture and pain. Review of the resident's clinical records including progress notes, physician's orders, quarterly evaluations and weight records, showed the resident experienced the following significant change of condition: a. Weight documentation reviewed between 03/03/23 and 08/03/23 noted the following: * 03/03/23:  117 pounds; * 04/03/23:  116 pounds; * 05/03/23:  No weight; * 06/03/23:  113.5 pounds; * 07/03/23:  112 pounds; and * 08/03/23:  106.2 pounds. Between 07/03/23 and 08/03/23, Resident 3 lost 5.8 pounds or 5.2% body weight in one month, representing significant weight loss and a significant change of condition. There was no documented evidence the facility evaluated the weight loss, determined what actions or intervention was needed for the resident, and referred the weight loss to the RN. Observations of the resident between 09/06/23 and 09/08/23 showed the resident was able to feed him/herself but would use their fingers to select finger foods and needed encouragement and cueing to eat. The resident did not seek out or ask for food items during survey observations but would accept items from staff when offered. During room visits on 09/06/23 at 12:10 pm, 09/07/23 at 9:45 am and 11:15 am, and 09/08/23 at 8:20 am, the resident was in bed and did not have any fluids available within reach. On 09/06/23, a request was made to obtain the resident's current weight. On 09/07/23, facility staff obtained the resident's weight and it was reported to be 92.4 pounds. Between 08/03/23 and 09/07/23, Resident 3 lost an additional 13.8 pounds or 12.21% body weight resulting in severe weight loss and a subsequent significant change of condition. The facility's failure to evaluate Resident 3's significant weight loss, determine what actions or interventions were needed, communicate the actions or interventions to staff, and refer the weight loss to the RN, resulted in severe weight loss. During a discussion relating to the resident's weight loss on 09/07/23 at 10:05 am, Staff 5 (Contractor) stated "we will start providing [the resident] protein shakes from the kitchen three times a day and update the doctor." b. Review of the resident's clinical records showed the resident experienced the following short term changes of condition: Resident 3 experienced four falls during the review period on: * On 06/30/23, the resident had complaints of back pain and was placed on alert monitoring; * On 08/08/23, the resident was complaining of hip pain after a fall and was placed on alert to monitor; * On 08/10/23, progress notes documented the resident had been found on the floor following another fall. The notes indicated the resident had been trying to walk to the bathroom when s/he fell; and * On 08/11/23, the resident sustained another fall when s/he was found on the floor next to the bed. There was no documented evidence the falls were evaluated to determine actions or interventions needed for the resident to prevent further falls. In addition, while the resident was placed on alert monitoring for pain related to falls, there was no evaluation to determine whether the resident's mobility had been affected. c. Review of the resident's clinical records showed the resident experienced the following additional short term changes of condition: * On 08/12/23 staff documented, "Resident is being placed on alert for pain in [his/her peri] area and not being able to turn with [his/her] left leg... unable to move [his/her] left leg to walk"; * Discontinuation of hydrocodone PRN pain medication on 08/22/23, which resident had been receiving at least weekly; and * "Symptoms of a urinary tract infection" on 08/22/23. The record lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution. The need to determine and document what actions or interventions were needed for residents who experienced short term changes of condition and ensure residents who experienced significant changes of condition were evaluated and referred to the RN was discussed with Staff 1 (ED) and Staff 5 on 09/08/23. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had significant changes of condition were evaluated, referred to the facility RN and service plans updated, failed to monitor and document what actions or interventions were needed for short-term changes of condition, including resident-specific instructions communicated to staff on each shift and made part of the resident's record with weekly progress noted through resolution for 5 of 5 sampled residents (#s 2, 3, 5, 6, and 7) who experienced changes of condition. Resident's 3 and 6 experienced severe weight loss. Findings include, but are not limited to:”

“Based on observation, interview and record review, it was determined the facility failed to conduct an RN assessment which included findings, resident status, and interventions made as a result of the assessment for 3 of 3 sampled residents (#s 3, 6 and 7) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2021 with diagnoses including dementia, hypertension and a history of pain. Weight documentation reviewed between 03/03/23 and 08/03/23 noted the following: * 03/03/23:  117 pounds; * 04/03/23:  116 pounds; * 05/03/23:  No weight; * 06/03/23:  113.5 pounds; * 07/03/23:  112 pounds; and * 08/03/23:  106.2 pounds. Between 07/03/23 and 08/03/23, Resident 3 lost 5.8 pounds or 5.2% body weight in one month, representing significant weight loss and a significant change of condition. A review Resident 3's most recent quarterly evaluation, dated 08/09/23, indicated the resident had no evidence of "dehydration or unexplained weight losses" within the last 90 days. There was no documented evidence the facility RN conducted an assessment which included findings, resident status and interventions made as a result. The RN failed to assess Resident 3's significant weight loss, determine what actions or interventions were needed, communicate the actions or interventions to staff, which resulted in severe weight loss. Refer to C270, example 3a. The need to ensure an RN assessment was conducted following significant changes of condition was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/08/23 and 09/11/23. They acknowledged the findings. Based on observation, interview and record review, it was determined the facility failed to conduct an RN assessment which included findings, resident status, and interventions made as a result of the assessment for 3 of 3 sampled residents (#s 3, 6 and 7) who experienced significant changes of condition. Findings include, but are not limited to:”

“Based on observation, interview and record review, it was determined the facility failed to ensure information and interventions provided by on-site and off-site outside providers were communicated to staff and service plans adjusted if necessary for 2 of 3 sampled residents (#s 3 and 5) who received outside services. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 07/2023 with diagnoses including dementia. Progress notes, which had outside provider documentation transcribed within them, dated 07/06/23 through 09/04/23, revealed the following home health recommendations lacked evidence they were communicated to staff and the plan of care was updated when necessary: * 07/06/23 - "loves puzzles, needs extra cues and encouragement to attend activities, is a social person, enjoys games, has a Nintendo Switch [hand held electronic gaming device], nicknames are Big Bear and Freddy Flinstone"; * 07/07/23 - "call ElderPlace for any concerns or changes of condition"; * 07/10/23 - "may benefit from a perimeter mattress"; * 07/13/23 - RN left the number to call and documented, "call ElderPlace with any questions or concerns"; * 07/27/23 - "replace dressing on knee abrasions if it comes off, call ElderPlace for increased redness, drainage, fever, pain"; * 08/10/23 - "watch for left hand bruising or bleeding, notify for signs or symptoms of infection to left knee, monitor for latent injuries or changes in ADL's related to fall"; and * 08/24/23 - "keep wounds covered, if dressing comes off or soiled, cleanse wound and cover with dressing." The facility lacked documented evidence the information and interventions were communicated to direct care staff. The need to ensure staff were informed of on-site outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on observation, interview and record review, it was determined the facility failed to ensure information and interventions provided by on-site and off-site outside providers were communicated to staff and service plans adjusted if necessary for 2 of 3 sampled residents (#s 3 and 5) who received outside services. Findings include, but are not limited to:”

“Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols and have a designated "Infection Control Specialist". Findings include, but are not limited to: 1. In an interview on 09/07/23, Staff 1 (ED) reported the facility did not have a designated individual to be the facility's "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols, qualified by education, training and experience or certification, and who had completed specialized training in infection prevention and control protocols. 2. Observations made between 09/06/23 and 09/08/23 showed facility staff failed to adhere to universal precautions for infection control in the following areas: a. On 09/06/23, Staff 23 (CG) was observed serving lunch in the dining room and clearing dirty dishes from tables. Staff 23 did not wash his/her hands between touching clean and dirty dishes and before touching multiple residents during the course of the lunch service. b. On 09/07/23, Staff 24 (CG) was observed wearing gloves without performing hand washing before and after donning gloves and moving between providing care to multiple residents out in the common areas. 3. During breakfast and lunch observations throughout the survey, direct care staff serving food in the Columbia and Deschutes units of the facility were not wearing aprons or some other barrier to prevent contamination between clothing and food. The need to ensure infection prevention protocols were followed and the facility had a qualified "Infection Control Specialist" was discussed with Staff 1, Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols and have a designated "Infection Control Specialist". Findings include, but are not limited to:”

“Based on observation, interview and record review, it was determined the facility failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to: Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas: C 302: Systems: Tracking Control Substances; C 303: Systems: Treatment Orders; C 310: Systems: Medication Administration; C 330: Systems: Psychotropic Medication; and Z 155: Staff Training Requirements as it related to MT documented competency of administering medications and treatments was demonstrated. The requirement to ensure adequate professional oversight of the medication administration system was discussed with Staff 1 (ED) and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on observation, interview and record review, it was determined the facility failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to: Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas: C 302: Systems: Tracking Control Substances; C 303: Systems: Treatment Orders; C 310: Systems: Medication Administration; C 330: Systems: Psychotropic Medication; and Z 155: Staff Training Requirements as it related to MT documented competency of administering medications and treatments was demonstrated. The requirement to ensure adequate professional oversight of the medication administration system was discussed with Staff 1 (ED) and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. The ED hired a new RN and new RCC, and is in the process of hiring a new LPN in order to ensure adequate professional oversight of the medication and treatment administration systems. The RN will be working a minumum 40 hrs a week. The RN will  take the "Role of the RN in a Community Based Care Facility" class. Medication and pharmacy audit will be conducted by the Licensed Nurse and pharmacy consultant. The outside consultant or designee will review the pharmacy audit and provide a inservice to the interdisciplinary team of the findings and put a plan in place to make needed corrections. The outside consultant or designee will complete a monthly audit of the medication and treatment systems. The outside consultant or designee will bring the above results to QAPI monthly for 3 months or until deficient practice has resolved. The ED hired a new RN and new RCC, and is in the process of hiring a new LPN in order to ensure adequate professional oversight of the medication and treatment administration systems. The RN will be working a minumum 40 hrs a week. The RN will  take the "Role of the RN in a Community Based Care Facility" class. Medication and pharmacy audit will be conducted by the Licensed Nurse and pharmacy consultant. The outside consultant or designee will review the pharmacy audit and provide a inservice to the interdisciplinary team of the findings and put a plan in place to make needed corrections. The outside consultant or designee will complete a monthly audit of the medication and treatment systems. The outside consultant or designee will bring the above results to QAPI monthly for 3 months or until deficient practice has resolved. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#2) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2023 with diagnoses including dementia and epilepsy. The resident had a signed physician order for lacosamide (a narcotic) 100 mg, one tablet by mouth two times a day for seizure disorder related to epilepsy. The medication was scheduled for administration at 8:00 am and 8:00 pm. Resident 2's Controlled Substance Disposition logs and MARs, reviewed from 06/01/23 through 09/05/23 revealed the following: * On 06/30/23, there was a blank on the 8:00 pm MAR entry but it was signed as administered on the disposition log; * On 07/02/23, there was a blank on the 8:00 pm MAR entry but it was signed as administered on the disposition log; * On 07/28/23, the MAR reflected the resident refused the medication but it was signed as administered on the disposition log; * On 08/13/23, the MAR reflected the medication was administered, but it wasn't signed on the disposition log; and * On 08/22/23, the MAR reflected staff couldn't find the medication but was signed as administered on the disposition log. There were two doses of lacosamide that the facility could not account for on 07/28/23 and 08/22/23 for the 8:00 pm administration. The need to ensure narcotic disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 1 (ED) on 09/06/23. She acknowledged the findings. Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#2) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2023 with diagnoses including dementia and epilepsy. The resident had a signed physician order for lacosamide (a narcotic) 100 mg, one tablet by mouth two times a day for seizure disorder related to epilepsy. The medication was scheduled for administration at 8:00 am and 8:00 pm. Resident 2's Controlled Substance Disposition logs and MARs, reviewed from 06/01/23 through 09/05/23 revealed the following: * On 06/30/23, there was a blank on the 8:00 pm MAR entry but it was signed as administered on the disposition log; * On 07/02/23, there was a blank on the 8:00 pm MAR entry but it was signed as administered on the disposition log; * On 07/28/23, the MAR reflected the resident refused the medication but it was signed as administered on the disposition log; * On 08/13/23, the MAR reflected the medication was administered, but it wasn't signed on the disposition log; and * On 08/22/23, the MAR reflected staff couldn't find the medication but was signed as administered on the disposition log. There were two doses of lacosamide that the facility could not account for on 07/28/23 and 08/22/23 for the 8:00 pm administration. The need to ensure narcotic disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 1 (ED) on 09/06/23. She acknowledged the findings. Resident 2 the RCC or designee will review controlled substances MAR and narcotic records to ensure documentation correlates. Medication and pharmacy audit wll be conducted by the Licensed Nurse and pharmacy consultant. The outside consultant or designee will review the pharmacy audit and provide an inservice to the interdisciplinary team of the findings and put a plan in place to make needed corrections. The outside consultant or desginee will provide an inservice to the interdisciplinary team and med tech on the importance of controlled subtances and medication treament administration. The RN or designee will do a weekly narcotic audit monthly. The RN or designee will bring the above results to QAPI monthly for 3 months or until deficient practice resolves. Resident 2 the RCC or designee will review controlled substances MAR and narcotic records to ensure documentation correlates. Medication and pharmacy audit wll be conducted by the Licensed Nurse and pharmacy consultant. The outside consultant or designee will review the pharmacy audit and provide an inservice to the interdisciplinary team of the findings and put a plan in place to make needed corrections. The outside consultant or desginee will provide an inservice to the interdisciplinary team and med tech on the importance of controlled subtances and medication treament administration. The RN or designee will do a weekly narcotic audit monthly. The RN or designee will bring the above results to QAPI monthly for 3 months or until deficient practice resolves. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and had signed physician orders for all medications and treatments the facility was responsible to administer for 4 of 6 sampled residents (#s 2, 3, 5, and 7) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 admitted to the facility in 06/2023 with diagnoses including dementia, epilepsy, and pain. The resident's MARs, dated 06/13/23 through 09/05/23, and physician's orders were reviewed and revealed the following: a. It was unclear if the following medications were administered as the MARs had blanks on the entries: * Levothyroxine (for hypothyroidism) on 06/19/23, 06/23/23, 06/25/23, 07/01/23, 07/08/23, 07/17/23, 08/29/23, and 08/31/23; * The 9:00 pm doses of Melatonin (for insomnia) and prevastatin (for hyperlipidemia) on 06/30/23, 07/02/23, 07/14/23, and 08/16/23; * The 8:00 pm doses of lacosamide (for seizures), memantine (for dementia), and acetaminophen (for pain) on 06/30/23 and 07/02/23; * The 8:00 pm treatment of diclofenac gel (for pain) on 06/03/23, 07/02/23, and 07/07/23; and * Multiple blanks on pain monitoring and weekly skin observations. b. The following medications were not administered as staff were unable to locate them: * Alendronate (for bone health) on 08/01/23; and * Lacosamide on 08/14/23 and 08/22/23. c. The following medications were not administered as prescribed due to the medication not being available at the facility: * Alendronate on 08/08/23; * Caltrate (for osteoporosis) on 07/13/23 and 07/14/23; * Losartan (for hypertensive heart disease) on 07/13/23 and 07/14/23; * PreserVision (for supplement) from 07/12/23 through 07/14/23; and * Memantine on 08/13/23. The need to ensure the facility administered all medications per physician's order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 07/2023 with diagnoses including dementia and Type 2 diabetes. The resident's progress notes, dated 07/06/23 through 09/04/23, MARs dated 08/01/23 through 09/05/23, and physician's orders were reviewed and revealed the following: a. It was unclear if the following medications were administered as the MARs had blanks on the entries: * Donepezil (for dementia) and Melatonin (for trouble sleeping) on 08/14/23 and 08/24/23; and * Novolin (for Type 2 diabetes) on 08/15/23 and 08/16/23. b. The following medications and treatments did not have current physician's orders: * Famotidine (for heartburn); and * Oxygen one liter per minute, to be used while sleeping. c. The following medications and treatments were not administered per physician's orders: * Trazodone (for dementia, trouble sleeping, anxiety) - the physician's order directed staff to administer one 50 mg tablet at bed time. The MAR directed staff to administer one and a half 50 mg tablets at bed time; * Metformin (for Type 2 diabetes) - the physician's order directed staff to administer one 500 mg tablet daily with breakfast and two 500 mg tablets daily with dinner. The MAR directed staff to administer two 500 mg tablets with breakfast and with dinner; and * Obtain CBGs at 8:00 am and at 5:00 pm prior to receiving insulin and eating a meal. - There was no documented evidence the facility took Resident 5's CBGs from 08/17/23 through 08/28/23; - There was no documented evidence the facility took the resident's CBGs at 8:00 am on 07/25/23, 08/31/23, 09/01/23, and 09/04/23; - There was no documented evidence the facility took Resident 5's CBGs at 5:00 pm on 08/16/23, 08/29/23, 08/30/23, and 09/02/23. d. The following medications and treatments were not administered as prescribed due to the medication not being available at the facility: * Bengay (for chronic knee pain) 07/20/23, 07/21/23, and 07/24/23; * Insulin (for Type 2 diabetes) on 07/24/23 as there were no syringes available; and * Cyanocobalamin (for inadequate B12) on 09/02/23. The need to ensure the facility administered all medications per physician's order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and had signed physician orders for all medications and treatments the facility was responsible to administer for 4 of 6 sampled residents (#s 2, 3, 5, and 7) whose orders were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure an accurate Medication Administrator Record (MAR) was kept for all medications and treatments that were ordered by a legally recognized prescriber and were administered by the facility for 3 of 6 sampled residents (#s 2, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2023 with diagnoses including dementia and pain. The resident's 06/01/23 through 09/05/23 MARs and physician orders were reviewed and identified the following: Resident 2 had an order for staff to "evaluate/observe pain level each shift" and gave instructions for, "0 = no pain to 10 = worst pain." The "hours" listed on the MAR specified, "Day, Eveni[ng], and Night." There was no numeric documentation of Resident 2's pain. The need to ensure MARs were accurate with clear parameters for staff was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the the findings. 2. Resident 5 was admitted in 07/2023 with diagnoses including dementia and venous insufficiency. The resident's 08/01/23 through 09/05/23 MARs were reviewed and identified the following: * Ammonium lactate external lotion (for venous insufficiency/stasis) was marked as not administered as the "resident was out of the facility" at 8:00 am on 08/10/23. Resident 5 received all other medications and treatments at 8:00 am on 08/10/23. * Circaid compression wraps (for venous insufficiency) was documented as the resident refused to have them taken off at 9:00 pm on 08/02/23. The compression wraps were signed as applied at 8:00 am on 08/03/23. * Miconazole powder (for yeast) had a section where staff were to document which "site" at 8:00 am and at 8:00 pm. There were multiple entries where staff documented applying the powder, but not the site applied. The need to ensure MARs were accurate was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure an accurate Medication Administrator Record (MAR) was kept for all medications and treatments that were ordered by a legally recognized prescriber and were administered by the facility for 3 of 6 sampled residents (#s 2, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were used only after documented non-pharmacological interventions to treat a resident's behavior were tried with ineffective results for 1 of 1 sampled resident (#7) who was prescribed a PRN medication to address anxiety. Findings include, but are not limited to: Resident 7 was admitted to the facility in 03/2023 with diagnoses including Alzheimer's disease with early onset and anxiety. The resident's 06/01/23 through 09/05/23 MARs, physician's orders, and 06/04/23 through 09/05/23 progress notes were reviewed. The resident was prescribed lorazepam 0.5 mg every eight hours as needed for severe anxiety. There were three non-pharmacological interventions listed on the MARs to attempt prior to administering the PRN psychotropic medication. Resident 7 was administered lorazepam on four occasions. There was no documented evidence non-pharmacological interventions were attempted with ineffective results prior to administration on the following dates: * 07/07/23; * 07/11/23; and * 09/04/23. In an interview on 09/06/23, Staff 15 (MT/CG) confirmed there were non-pharmacological interventions to offer Resident 7, but they were not documented as attempted in the MARs or progress notes. The need to ensure documented, non-pharmacological interventions had been tried with ineffective results prior to the administration of a PRN psychotropic medication was discussed with Staff 1(ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were used only after documented non-pharmacological interventions to treat a resident's behavior were tried with ineffective results for 1 of 1 sampled resident (#7) who was prescribed a PRN medication to address anxiety. Findings include, but are not limited to: Resident 7 was admitted to the facility in 03/2023 with diagnoses including Alzheimer's disease with early onset and anxiety. The resident's 06/01/23 through 09/05/23 MARs, physician's orders, and 06/04/23 through 09/05/23 progress notes were reviewed. The resident was prescribed lorazepam 0.5 mg every eight hours as needed for severe anxiety. There were three non-pharmacological interventions listed on the MARs to attempt prior to administering the PRN psychotropic medication. Resident 7 was administered lorazepam on four occasions. There was no documented evidence non-pharmacological interventions were attempted with ineffective results prior to administration on the following dates: * 07/07/23; * 07/11/23; and * 09/04/23. In an interview on 09/06/23, Staff 15 (MT/CG) confirmed there were non-pharmacological interventions to offer Resident 7, but they were not documented as attempted in the MARs or progress notes. The need to ensure documented, non-pharmacological interventions had been tried with ineffective results prior to the administration of a PRN psychotropic medication was discussed with Staff 1(ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. The RCC or designee will ensure that there are non- pharmaceutical  interventions for resident 7 and they are service planned. The RCC or designee will ensure that the psychotropic medication for resident 7 has a space provided to document prior to medication administration. The RCC or the designee will audit all residents with PRN psychotrospic med and insure that non pharmaceutical interventions are in place. The ouside consultant or the designee will hold a staff meeting with the med techs and interdisciplinary team on the management and administration of psychotropic medications. The RCC or designee will complete a 10% audit of the residents receiving psychotropic meds monthly to ensure that nonpharmaceutical interventions are tried prior to administration. The RCC will bring the above audit to QAPI meeting monthly for 3 months or until deficient practice resolves. The RCC or designee will ensure that there are non- pharmaceutical  interventions for resident 7 and they are service planned. The RCC or designee will ensure that the psychotropic medication for resident 7 has a space provided to document prior to medication administration. The RCC or the designee will audit all residents with PRN psychotrospic med and insure that non pharmaceutical interventions are in place. The ouside consultant or the designee will hold a staff meeting with the med techs and interdisciplinary team on the management and administration of psychotropic medications. The RCC or designee will complete a 10% audit of the residents receiving psychotropic meds monthly to ensure that nonpharmaceutical interventions are tried prior to administration. The RCC will bring the above audit to QAPI meeting monthly for 3 months or until deficient practice resolves. There are no detail notes for this visit.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, failed to instruct caregivers on the correct use and precautions related to the use of the device, and failed to include the use of the supportive device in the service plan and evaluated on a quarterly basis for 3 of 3 sampled residents (#s 3, 5, and 6) who used a supportive device with restraining qualities. Findings include, but are not limited to: 1. Resident 6 moved into the facility in 01/2023 with diagnoses including dementia and insomnia. Observations of the resident and interviews with staff indicated the resident had a quarter-length side rail on the left side of his/her bed. The side rail was in good repair and flush with the mattress. The resident's Individual Service Plan Report, dated 06/22/23, contained no information regarding the side rail. Staff reported the resident was primarily bedbound and received the hospital bed with side rail from the hospice provider. On 09/06/23, Staff 3 (RCC) confirmed an assessment of the side rail was not completed. The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and were included in the resident's service plan was discussed with Staff 1(ED), Staff 2 (RN), Staff 3, and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, failed to instruct caregivers on the correct use and precautions related to the use of the device, and failed to include the use of the supportive device in the service plan and evaluated on a quarterly basis for 3 of 3 sampled residents (#s 3, 5, and 6) who used a supportive device with restraining qualities. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity Based Staffing Tool (ABST) was reviewed before a resident moved in to the facility, updated with each significant change of condition, was updated no less than quarterly, and the entries were reflective of the resident's current care needs for 6 of 6 residents reviewed (#s 2, 3, 4, 5, 6, and 7). Findings include, but are not limited to: 1. A review of the facility's ABST on 09/08/23 revealed the facility failed to enter the newly admitted residents before move in, updated the residents identified as having significant changes of condition, and update all residents no less than quarterly. 2. Resident 2 was admitted to the facility on 06/13/23 with diagnoses including dementia. a. Per the facility's ABST, the resident's information was inputted on 06/14/23. b. Observations of Resident 2, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs and had an inaccurate amount of minutes assigned in the following areas: * Personal hygiene; * Bathing; * Non-drug interventions for pain management; * Providing treatments; * Cueing or redirecting due to cognitive impairment or dementia; * Non-drug interventions for behaviors; and * Monitoring physical conditions. 3. Resident 5 was admitted to the facility on 07/06/23 with diagnoses including dementia. a. Per the facility's ABST, the resident's information was inputted on 07/06/23. b. Observations of Resident 5, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs and had an inaccurate amount of minutes assigned in the following areas: * Dressing and undressing; * Bowel and bladder management; * Bathing; * Medication administration; * Providing treatments; * Monitoring physical conditions or symptoms; * Assisting with assistive devices for hearing and vision; * Responding to call lights; and * Safety checks and fall interventions. The need to ensure residents were entered into the ABST system prior to moving into the facility, updated with each significant change of condition, updated no less than quarterly, and the entries were reflective of the resident's care needs was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity Based Staffing Tool (ABST) was reviewed before a resident moved in to the facility, updated with each significant change of condition, was updated no less than quarterly, and the entries were reflective of the resident's current care needs for 6 of 6 residents reviewed (#s 2, 3, 4, 5, 6, and 7). Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure 5 of 5 direct care staff (#s 8, 10, 11, 12, and 21) had documented evidence for completion of First Aid certification and training in abdominal thrust within 30 days of hire, and direct care staff had sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. Findings include, but are not limited to: a. Staff training records were reviewed on 09/05/23 at 1:00 pm. The following direct care staff lacked documented evidence First Aid and abdominal thrust training was completed within 30 days of hire: Staff 08 (MT/Staffing Coordinator), hired on 07/27/23; Staff 10 (MT/CG), hired on 03/27/23; Staff 11 (MT), hired on 07/18/23; Staff 12 (MT), hired on 07/27/23; and Staff 21 (CG), hired on 02/25/23. b. Multiple care staff lacked sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. On 09/05/23, at approximately 10:45 am, an interview with Staff 21 (CG) revealed she was unable to respond with sufficient communication and language skills to direct the survey team to the service plan binder on the unit. On 09/06/23 and 09/07/23, Staff 23 (CG) was interviewed regarding care being provided to Resident 3. Staff 23 was unable to respond with sufficient communication and language skills to enable communication. On 09/07/23 at 9:20 am, Staff 24 (CG) was interviewed regarding care being provided to Resident 6. Staff 24 was unable to respond with sufficient communication and language skills regarding diet orders for Resident 6. The need to ensure newly hired direct care staff completed all required training in the specified time frames and staff had sufficient communication skills was discussed with Staff 1 (ED) on 09/05/23 and with Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. No further information was provided. Based on interview and record review, it was determined the facility failed to ensure 5 of 5 direct care staff (#s 8, 10, 11, 12, and 21) had documented evidence for completion of First Aid certification and training in abdominal thrust within 30 days of hire, and direct care staff had sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. Findings include, but are not limited to: a. Staff training records were reviewed on 09/05/23 at 1:00 pm. The following direct care staff lacked documented evidence First Aid and abdominal thrust training was completed within 30 days of hire: Staff 08 (MT/Staffing Coordinator), hired on 07/27/23; Staff 10 (MT/CG), hired on 03/27/23; Staff 11 (MT), hired on 07/18/23; Staff 12 (MT), hired on 07/27/23; and Staff 21 (CG), hired on 02/25/23. b. Multiple care staff lacked sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. On 09/05/23, at approximately 10:45 am, an interview with Staff 21 (CG) revealed she was unable to respond with sufficient communication and language skills to direct the survey team to the service plan binder on the unit. On 09/06/23 and 09/07/23, Staff 23 (CG) was interviewed regarding care being provided to Resident 3. Staff 23 was unable to respond with sufficient communication and language skills to enable communication. On 09/07/23 at 9:20 am, Staff 24 (CG) was interviewed regarding care being provided to Resident 6. Staff 24 was unable to respond with sufficient communication and language skills regarding diet orders for Resident 6. The need to ensure newly hired direct care staff completed all required training in the specified time frames and staff had sufficient communication skills was discussed with Staff 1 (ED) on 09/05/23 and with Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. No further information was provided. ED ensured that all med techs without proper training were removed from the cart until med tech training and competencies were verified. ED ensured all untrained med techs training and competencies were complete. Outside consultant completed a full staff audit of missing trainings and competencies to include first aid, abdominal thrust. Outside Consultant alerted all staff to complete all trainings. Outside consultant scheduled a first aid/abdominal thrust class in the facilty for staff to attend. Outside consultant completed a training tracker and has placed all staff training on the tracker. ED or designee will evaluate all staff to identify any that require interpretation or service plans in alternate languages to ensure staff are able to sufficiently communicate. ED or designee will do a weekly 10% audit of all staff to ensure that their sufficient communication evaluation as well as abdominal thrust training is complete and placed in training binder. ED or Designee will bring the above audit to QAPI for 3 months or until deficient practice is resolved. ED ensured that all med techs without proper training were removed from the cart until med tech training and competencies were verified. ED ensured all untrained med techs training and competencies were complete. Outside consultant completed a full staff audit of missing trainings and competencies to include first aid, abdominal thrust. Outside Consultant alerted all staff to complete all trainings. Outside consultant scheduled a first aid/abdominal thrust class in the facilty for staff to attend. Outside consultant completed a training tracker and has placed all staff training on the tracker. ED or designee will evaluate all staff to identify any that require interpretation or service plans in alternate languages to ensure staff are able to sufficiently communicate. ED or designee will do a weekly 10% audit of all staff to ensure that their sufficient communication evaluation as well as abdominal thrust training is complete and placed in training binder. ED or Designee will bring the above audit to QAPI for 3 months or until deficient practice is resolved. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills were conducted and recorded every other month per Oregon Fire Code (OFC), fire and life safety training was conducted on alternate months of the fire drills, and a written fire drill record was kept. Findings include, but are not limited to: Fire drill and fire and life safety records were requested on 09/05/23 at 12:00 pm. a. The facility failed to keep a written fire drill record that included the following required components: * Date and time of day; * Location of simulated fire origin; * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Staff members on duty and participating; * Number of occupants evacuated; and * Alternate exit routes were used during fire drills to react to varying potential fire origin points. b. There was no documented evidence fire and life safety training for staff was conducted and recorded on alternating months of fire drills. On 09/05/23 at 12:30 pm, Staff 4 (Maintenance Director) reported he was unable to locate any fire drill or fire and life safety training records for staff. The need to ensure fire drills were conducted and recorded every other month per Oregon Fire Code (OFC), and staff were instructed on fire and life safety training on alternating months of the fire drills was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. No further information was provided. Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills were conducted and recorded every other month per Oregon Fire Code (OFC), fire and life safety training was conducted on alternate months of the fire drills, and a written fire drill record was kept. Findings include, but are not limited to: Fire drill and fire and life safety records were requested on 09/05/23 at 12:00 pm. a. The facility failed to keep a written fire drill record that included the following required components: * Date and time of day; * Location of simulated fire origin; * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Staff members on duty and participating; * Number of occupants evacuated; and * Alternate exit routes were used during fire drills to react to varying potential fire origin points. b. There was no documented evidence fire and life safety training for staff was conducted and recorded on alternating months of fire drills. On 09/05/23 at 12:30 pm, Staff 4 (Maintenance Director) reported he was unable to locate any fire drill or fire and life safety training records for staff. The need to ensure fire drills were conducted and recorded every other month per Oregon Fire Code (OFC), and staff were instructed on fire and life safety training on alternating months of the fire drills was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. No further information was provided. The ouside consultant or designee will review the fire life and safety policy and protocols with the Maintenace Director. The Maintenance Director or designee will conduct fire drill and staff training as directed in the OAR monthly. The ED or designee will audit for compliance monthly. The ED or designee will bring the above audit to QAPI for 3 months or until the deficient practice is resolved. The ouside consultant or designee will review the fire life and safety policy and protocols with the Maintenace Director. The Maintenance Director or designee will conduct fire drill and staff training as directed in the OAR monthly. The ED or designee will audit for compliance monthly. The ED or designee will bring the above audit to QAPI for 3 months or until the deficient practice is resolved. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure residents were instructed about the facility's fire and life safety procedures per Oregon Fire Code (OFC), within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire and a written record of fire safety training, including content of the training sessions and the residents attending was kept. Findings include, but are not limited to: Fire and life safety records for residents were requested on 09/05/23 at 12:00 pm. On 09/05/23 at 12:30 pm, Staff 4 (Maintenance Director) reported he was unable to locate any fire drill records for the building or resident fire and life safety training records. The need to ensure residents were instructed about the facility's fire and life safety procedures per Oregon Fire Code (OFC), within 24 hours of admission and re-instructed, at least annually was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. No further information was provided. Based on interview and record review, it was determined the facility failed to ensure residents were instructed about the facility's fire and life safety procedures per Oregon Fire Code (OFC), within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire and a written record of fire safety training, including content of the training sessions and the residents attending was kept. Findings include, but are not limited to: Fire and life safety records for residents were requested on 09/05/23 at 12:00 pm. On 09/05/23 at 12:30 pm, Staff 4 (Maintenance Director) reported he was unable to locate any fire drill records for the building or resident fire and life safety training records. The need to ensure residents were instructed about the facility's fire and life safety procedures per Oregon Fire Code (OFC), within 24 hours of admission and re-instructed, at least annually was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. No further information was provided. The ouside consultant or designee will review the fire life and safety policy and protocols with the Maintenance Director. The Maintenance Director or designee will instruct all residents about fire and life safty procedures with any new move in within 24 hrs.Aall residents will be reinstructed annually. The Maintenance Director or designee will conduct fire drills and staff training to meet the requirement. The ED or desginee will audit new admits to ensure they have fire and life safety training as required. The ED or designee will bring the above audit to QAPI for 3 months or until the deficient practice is resolved. The ouside consultant or designee will review the fire life and safety policy and protocols with the Maintenance Director. The Maintenance Director or designee will instruct all residents about fire and life safty procedures with any new move in within 24 hrs.Aall residents will be reinstructed annually. The Maintenance Director or designee will conduct fire drills and staff training to meet the requirement. The ED or desginee will audit new admits to ensure they have fire and life safety training as required. The ED or designee will bring the above audit to QAPI for 3 months or until the deficient practice is resolved. Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety procedures at least annually. This is a repeat citation. Findings include, but are not limited to: Fire and life safety records were requested and reviewed with Staff 33 (Maintenance) on 04/09/24 and 04/10/24 and the following deficiencies were identified: * There was no documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire and life safety training provided at least annually. The need to ensure residents received fire and life safety training at least annually was discussed with Staff 28 (ED), Staff 33 and Witness 2 (Consultant, LPN) on 04/10/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety procedures at least annually. This is a repeat citation. Findings include, but are not limited to: Fire and life safety records were requested and reviewed with Staff 33 (Maintenance) on 04/09/24 and 04/10/24 and the following deficiencies were identified: * There was no documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire and life safety training provided at least annually. The need to ensure residents received fire and life safety training at least annually was discussed with Staff 28 (ED), Staff 33 and Witness 2 (Consultant, LPN) on 04/10/24. 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 C231, C260, C295, C303, C310, C422, C510 and Z155. 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 C231, C260, C295, C303, C310, C422, C510 and Z155. Refer to C231, C260, C295, C303, C310, C422, C510, Z155 Refer to C231, C260, C295, C303, C310, C422, C510, Z155 There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit. Findings include, but are not limited to: The interior of the building was toured on 09/05/23 at 9:14 am. The following issues were noted: a. On 09/05/23, toxic disinfectant in a spray bottle was in an unlocked kitchenette cabinet in the Clackamas Neighborhood and in the Columbia Neighborhood. The kitchenettes were open for residents to enter without staff assistance or supervision. During a tour of the facility on 09/05/23, with Staff 1 (ED), the disinfectant spray bottles were removed. b. On 09/08/23 at 9:40 am, in the Clackamas Neighborhood, a disinfectant spray bottle was observed on top of a table in the dining room. c. On 09/08/23 at 9:45 am, in the Deschutes Neighborhood, a disinfectant spray bottle was observed on top of a side table within reach of multiple residents. The need to ensure all toxic materials were maintained in locked storage was discussed with Staff 1, Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit. Findings include, but are not limited to: The interior of the building was toured on 09/05/23 at 9:14 am. The following issues were noted: a. On 09/05/23, toxic disinfectant in a spray bottle was in an unlocked kitchenette cabinet in the Clackamas Neighborhood and in the Columbia Neighborhood. The kitchenettes were open for residents to enter without staff assistance or supervision. During a tour of the facility on 09/05/23, with Staff 1 (ED), the disinfectant spray bottles were removed. b. On 09/08/23 at 9:40 am, in the Clackamas Neighborhood, a disinfectant spray bottle was observed on top of a table in the dining room. c. On 09/08/23 at 9:45 am, in the Deschutes Neighborhood, a disinfectant spray bottle was observed on top of a side table within reach of multiple residents. The need to ensure all toxic materials were maintained in locked storage was discussed with Staff 1, Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. The ED and Maintenane Director idenifted 4 cupboards in each community where locks will be installled and chemicals and toxic material will be stored. ED or designee will hold an all staff meeting to ensure that chemical and toxic materials are locked and stored at all times. Maintance Director or designee will do a weekly audit to ensure all chemical and toxic materials are locked in storage cabinets. Maintance Director or designee will bring the above audits to QAPI for 3 months or until the deficient practice is resolved. The ED and Maintenane Director idenifted 4 cupboards in each community where locks will be installled and chemicals and toxic material will be stored. ED or designee will hold an all staff meeting to ensure that chemical and toxic materials are locked and stored at all times. Maintance Director or designee will do a weekly audit to ensure all chemical and toxic materials are locked in storage cabinets. Maintance Director or designee will bring the above audits to QAPI for 3 months or until the deficient practice is resolved. Based on observation and interview, it was determined the facility failed to ensure toxic materials were secured in locked storage. This is a repeat citation. Findings include, but are not limited to: The facility was toured on 04/09/24 at 9:45 am. The following toxic materials were found in unlocked cupboards in each of the four neighborhood kitchenettes: * A 1.25 gallon of Lysol disinfectant was in the Deschutes, Columbia, Clackamas, and Sandy neighborhoods. * Two spray bottles of 730 HP disinfectant cleaner were in the Columbia and Clackamas neighborhoods, and one spray bottle of 730 HP disinfectant cleaner was in the Sandy neighborhood. * A spray bottle of ZEP air and fabric odor eliminator was in the Deschutes neighborhood. The kitchenettes were accessible to residents and throughout the survey residents were observed entering the kitchenettes. On 04/09/24 at 10:20 the facility was directed to removed these chemicals to secured locked storage, which was confirmed as completed. The need to ensure all toxic materials were maintained in locked storage was discussed with Staff 28 (Executive Director) and Staff 33 (Maintenance) on 04/10/24. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure toxic materials were secured in locked storage. This is a repeat citation. Findings include, but are not limited to: The facility was toured on 04/09/24 at 9:45 am. The following toxic materials were found in unlocked cupboards in each of the four neighborhood kitchenettes: * A 1.25 gallon of Lysol disinfectant was in the Deschutes, Columbia, Clackamas, and Sandy neighborhoods. * Two spray bottles of 730 HP disinfectant cleaner were in the Columbia and Clackamas neighborhoods, and one spray bottle of 730 HP disinfectant cleaner was in the Sandy neighborhood. * A spray bottle of ZEP air and fabric odor eliminator was in the Deschutes neighborhood. The kitchenettes were accessible to residents and throughout the survey residents were observed entering the kitchenettes. On 04/09/24 at 10:20 the facility was directed to removed these chemicals to secured locked storage, which was confirmed as completed. The need to ensure all toxic materials were maintained in locked storage was discussed with Staff 28 (Executive Director) and Staff 33 (Maintenance) on 04/10/24. They acknowledged the findings.”

“Based on observation and interview, the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used when washing soiled linens and soiled clothing. Findings include, but are not limited to: The facility laundry area was toured on 09/05/23 at 11:15 am with Staff 4 (Maintenance Director). Staff 4 reported the facility hot water system was designed on a "loop system" which meant all areas of the facility were on a continuous hot water system. The hot water system had to be maintained at 120 degrees F. or lower because the hot water also served resident units. Staff 4 reported when he started approximately a month ago the facility had a chemical disinfectant that was on an automatic dispense into the washers that were dedicated for soiled clothing and linen however, they were disconnected and stored in a garage in the back perimeter of the property. Staff 4 confirmed the care staff were currently not using a chemical disinfectant when washing soiled clothing. The need to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on observation and interview, the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used when washing soiled linens and soiled clothing. Findings include, but are not limited to: The facility laundry area was toured on 09/05/23 at 11:15 am with Staff 4 (Maintenance Director). Staff 4 reported the facility hot water system was designed on a "loop system" which meant all areas of the facility were on a continuous hot water system. The hot water system had to be maintained at 120 degrees F. or lower because the hot water also served resident units. Staff 4 reported when he started approximately a month ago the facility had a chemical disinfectant that was on an automatic dispense into the washers that were dedicated for soiled clothing and linen however, they were disconnected and stored in a garage in the back perimeter of the property. Staff 4 confirmed the care staff were currently not using a chemical disinfectant when washing soiled clothing. The need to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Outside consultant will review the minimum rinse temperatures with the owner of the property and Maintenance Director. Outside consultant will  reach out to Eco Lab to have the chemical system reinstalled. Maintenance Director will ensure chemical disinfectant is functional with weekly rounds. Maintenance Director will bring audits to QAPI monthly for 3 months or until deficient practice has resolved. Outside consultant will review the minimum rinse temperatures with the owner of the property and Maintenance Director. Outside consultant will  reach out to Eco Lab to have the chemical system reinstalled. Maintenance Director will ensure chemical disinfectant is functional with weekly rounds. Maintenance Director will bring audits to QAPI monthly for 3 months or until deficient practice has resolved. There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to: Observations on 09/05/23 at 11:40 am, identified exit doors to the "Garden" interior courtyard in the Clackamas and Sandy Neighborhoods did not have an operable alarm or other acceptable system to alert staff when residents exited the building. On 09/05/23, Staff (CG), stated "usually I hear an alarm when they go outside, but I don't hear it today." The failure to ensure exit doors were equipped with an alarming device or other acceptable system and were operable was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to: Observations on 09/05/23 at 11:40 am, identified exit doors to the "Garden" interior courtyard in the Clackamas and Sandy Neighborhoods did not have an operable alarm or other acceptable system to alert staff when residents exited the building. On 09/05/23, Staff (CG), stated "usually I hear an alarm when they go outside, but I don't hear it today." The failure to ensure exit doors were equipped with an alarming device or other acceptable system and were operable was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Outside consultant performed a full facility walk through identifying all exit doors that were not alarming. Maintenance Director or designee will ensure all exit doors have a fully functioinal alarming device in place. Maintenance Director or designee will complete a weekly audit insuring all alarms are fully functional. Maintenance Director or desgine will bring the results of the above  audits to QAPI monthly for 3 months or until the deficient practice is resolved. Outside consultant performed a full facility walk through identifying all exit doors that were not alarming. Maintenance Director or designee will ensure all exit doors have a fully functioinal alarming device in place. Maintenance Director or designee will complete a weekly audit insuring all alarms are fully functional. Maintenance Director or desgine will bring the results of the above  audits to QAPI monthly for 3 months or until the deficient practice is resolved. There are no detail notes for this visit.”

“Concerns were identified and the facility was provided with technical assistance in the following areas: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. Concerns were identified and the facility was provided with technical assistance in the following areas: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. There are no detail notes for this visit.”

“Concerns were identified and the facility was provided with technical assistance in the following areas: (d) Each individual has privacy in his or her own unit. Concerns were identified and the facility was provided with technical assistance in the following areas: (d) Each individual has privacy in his or her own unit. There are no detail notes for this visit.”

“Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to: The licensee is responsible for the operation of the MCC and the provision of person-directed care that promotes each resident's dignity, independence, and comfort. This included the supervision and training of the staff. During the re-licensure survey, conducted 09/05/23 through 09/08/23, and 09/11/23, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number and severity of citations. 1.  A situation was identified which constituted an immediate plan of correction to residents' health and safety in the following areas: OAR 411-054-0036 (1), (2), & (4) Service plans; OAR 411-057-0140 (1) Administration Responsibilities; OAR 411-057-0155 (3) Staff Training Requirements; and OAR 411-057-0160 (2b) Compliance with Rules - Health Care. The facility put an immediate plan of correction in place during the survey and the situation was abated. 2.  Refer to deficiencies in the report. Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to: The licensee is responsible for the operation of the MCC and the provision of person-directed care that promotes each resident's dignity, independence, and comfort. This included the supervision and training of the staff. During the re-licensure survey, conducted 09/05/23 through 09/08/23, and 09/11/23, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number and severity of citations.”

“Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 200, C 231, C 295, C 361, C 372, C 420, C 422, C 510, C 530, and C 555. Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 200, C 231, C 295, C 361, C 372, C 420, C 422, C 510, C 530, and C 555. Refer to POC for C200, C231, C295, C361, C372, C420, C422, C510, C530 and C555. Refer to POC for C200, C231, C295, C361, C372, C420, C422, C510, C530 and C555. 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 C231, C295, C422, and C510. 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 C231, C295, C422, and C510. Refer to C231, C295, C422, C510 Refer to C231, C295, C422, C510 There are no detail notes for this visit.”

“Based on observation, interview, and record review, it was determined the facility failed to have documented evidence of required pre-service orientation, pre-service dementia training and demonstrated competency within 30 days of hire for 5 of 5 newly hired staff (#s 8, 10, 11, 12, and 21), completion of annual infectious disease prevention for 2 of 2 non direct care staff, and a total of 16 hours of annual in-service training which included 6 hours of dementia care topics for 3 of 4 (#s 9,18, and 22). Additionally, the facility failed to ensure 6 of 10 MT's (#s 8,10,11,12, 17, and 27) had documented evidence of completion of medication administration competency. This constituted a situation which put resident care needs at risk related to a lack of medication training. Findings include, but are not limited to: Staff training records were reviewed on 09/05/23 and 09/08/23 and the following was identified. 1. On 09/08/23, the survey team asked to review all MT competency training. The facility failed to ensure 6 of 10 MT's (#s 8,10,11,12, 17, and 27), completed required competency training in medication and treatment administration. On 09/08/23 Staff 17 (MT/CG) was observed passing medications to residents without having completed medication competency, at which time survey requested an immediate plan of correction which included removing all untrained MT's from the task of passing medications and treatments until training was completed and competency was demonstrated. The survey team received the immediate plan of correction on 09/08/23 at 6:23 pm. On 09/11/23 at 11:06 am, Staff 17 was observed passing medication to residents. On 09/11/23 at 11:23 am, the surveyor discussed the observation with Staff 1 (ED) and requested Staff 17's documented medication competency. Staff 1 stated, "we are aware, [Staff 9 (MT)] was supposed to train her [Staff 17] last week [on 09/08/23], but the training didn't happen. She [Staff 9], is coming in right now and will train and shadow her until the medication competency is completed." Later in the day on 09/11/23, observations confirmed Staff 9 was training and working with Staff 17. The situation was abated. 2. Training records for Staff 8 (MT/Staffing Coordinator), Staff 10 (MT/CG), Staff 11 (MT), Staff 12 (MT), Staff 17 (MT), Staff 21 (CG), and Staff 27 (MT), hired on 07/27/23, 03/27/23, 07/18/23, 04/10/23, 07/27/23, 02/25/23, and 03/10/23, respectively, identified the following: a. Staff 8, 10, 11, 12, and 21 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in all or some of the following areas: * Resident rights and values of community based care; * Abuse reporting requirements; * Infectious disease prevention; * Fire safety and emergency procedures; and * Written job description. b. Staff 8, 10, 11, 12, and 21 lacked documented evidence pre-service dementia training including how to provide personal care to residents with dementia, an orientation to the resident's service plan and the use of supportive devices with restraining qualities was completed prior to independently providing care and services to residents. 3. Staff 8, 10, 11, 12, 17, 21, and 27, lacked documented evidence of knowledge and performance demonstrated within 30 days of hire in one or more of the following required areas: * Role of the service plan in providing individualized care; * Providing assistance with ADL's; * Changes associated with normal aging; * Identification, documentation and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving, and sanitation; and * Other duties as applicable, which included competency in medication and treatment administration. 4. Staff 25 (Dietary) and Staff 26 (Housekeeping), hired 04/13/21 and 08/15/18, respectively, lacked documented evidence for completion of annual infectious disease prevention training. 5. Staff 09 (MT/CG), Staff 18 (CG) and Staff 22 (CG), hired 07/20/17, 09/14/17, and 05/13/19 respectively, lacked documented evidence of completion of 16 hours of annual in-service training which included annual infection control training and at least six hours of dementia care training. The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to have documented evidence of required pre-service orientation, pre-service dementia training and demonstrated competency within 30 days of hire for 5 of 5 newly hired staff (#s 8, 10, 11, 12, and 21), completion of annual infectious disease prevention for 2 of 2 non direct care staff, and a total of 16 hours of annual in-service training which included 6 hours of dementia care topics for 3 of 4 (#s 9,18, and 22). Additionally, the facility failed to ensure 6 of 10 MT's (#s 8,10,11,12, 17, and 27) had documented evidence of completion of medication administration competency. This constituted a situation which put resident care needs at risk related to a lack of medication training. Findings include, but are not limited to: Staff training records were reviewed on 09/05/23 and 09/08/23 and the following was identified.”

“Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 262, C 270, C 280, C 290, C 300, C 302, C 303, C 310, C 330, and C 340. Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 262, C 270, C 280, C 290, C 300, C 302, C 303, C 310, C 330, and C 340. Refer to POC to C252, C260, C262, C280, C290, C300, C302, C303, C310, C330, and C340. Refer to POC to C252, C260, C262, C280, C290, C300, C302, C303, C310, C330, and C340. 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. This is a repeat citation. Findings include, but are not limited to: Refer to C260, C303, 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. This is a repeat citation. Findings include, but are not limited to: Refer to C260, C303, and C310. Refer to C260, C303, and C310 Refer to C260, C303, and C310 There are no detail notes for this visit.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 5 of 7 sampled residents (#s 2, 3, 4, 5, and 8), whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 8 moved into the memory care community in April 2023. On 09/11/23, Resident 8 was observed to sleep in later in the morning and missed breakfast. On 09/11/23 at 9:08 am, Staff 20 (CG) reported Resident 8 often sleeps in. "We save a plate in the warmer cart for awhile until we need to send it back. We can give [the resident] a snack." An alternative meal option was not offered. Resident 8's "individualized service plan report" (s) dated 06/22/23 and 07/14/23 were reviewed. There was no documented evidence the facility developed and implemented an individualized nutrition and hydration plan which included information regarding missed meals, alternative meal options, or food and fluid preferences. The need to ensure the facility developed individualized nutrition and hydration plans for Resident 8 was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 5 of 7 sampled residents (#s 2, 3, 4, 5, and 8), whose service plans were reviewed. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations addressed all required components, and individualized activity plans were developed for 7 of 7 sampled residents (#s 2, 3, 4, 5, 6, 7, and 8) whose activity plans were reviewed. Findings include, but are not limited to: Resident's 2, 3, 4, 5, 6, 7, and 8's records were reviewed and observations were made during the survey. There was no documented evidence activity evaluations were completed and included the following: * Past and current interests; * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitation; * Adaptations needed to participate; * Identification of activities for behavioral interventions; and * There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities. The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. The findings were acknowledged. Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations addressed all required components, and individualized activity plans were developed for 7 of 7 sampled residents (#s 2, 3, 4, 5, 6, 7, and 8) whose activity plans were reviewed. Findings include, but are not limited to: Resident's 2, 3, 4, 5, 6, 7, and 8's records were reviewed and observations were made during the survey. There was no documented evidence activity evaluations were completed and included the following: * Past and current interests; * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitation; * Adaptations needed to participate; * Identification of activities for behavioral interventions; and * There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities. The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. The findings were acknowledged. Outside consultant or designee will provide training to Activities staff on how to complete evlauations and service plans. Activities Director or designee will complete resident 2 evaluation and make TSP/SP updates. Activities Director or designee will complete resident 3 evaluation and make TSP/SP updates. Activities Director or designee will complete resident 4 evaluation and make TSP/SP updates. Activities Director or designee will complete resident 5 evaluation and make TSP/SP updates. Resident 6 has passed away. Activities Director or designee will complete resident 7 evaluation and make TSP/SP updates. Activities Director or designee will complete resident 8 evaluation and make TSP/SP updates. Activities Director or designee will complete a full house audit identifying all residents who need an updated evaluation and SP. Activities Director or Designee will complete the identified evaluations and SP/TSP. Activities Director attended a Life Enrichement Webinar  9/23/23 through Oregon Care partners for further training and education. ED or designee will do a weekly audit reviewing two SP to ensure that they have person-centered, meaningful activites present. ED or designee will bring the results of the above audit to QAPI for 3 consecutive months or until deficient practice resolves. Outside consultant or designee will provide training to Activities staff on how to complete evlauations and service plans. Activities Director or designee will complete resident 2 evaluation and make TSP/SP updates. Activities Director or designee will complete resident 3 evaluation and make TSP/SP updates. Activities Director or designee will complete resident 4 evaluation and make TSP/SP updates. Activities Director or designee will complete resident 5 evaluation and make TSP/SP updates. Resident 6 has passed away. Activities Director or designee will complete resident 7 evaluation and make TSP/SP updates. Activities Director or designee will complete resident 8 evaluation and make TSP/SP updates. Activities Director or designee will complete a full house audit identifying all residents who need an updated evaluation and SP. Activities Director or Designee will complete the identified evaluations and SP/TSP. Activities Director attended a Life Enrichement Webinar  9/23/23 through Oregon Care partners for further training and education. ED or designee will do a weekly audit reviewing two SP to ensure that they have person-centered, meaningful activites present. ED or designee will bring the results of the above audit to QAPI for 3 consecutive months or until deficient practice resolves. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure resident behaviors which negatively impacted themselves or others were evaluated and included in the service plan for 2 of 3 sampled residents (#s 2 and 8). Resident 8 repeatedly exhibited verbal and physically aggressive behaviors that negatively impacted him/herself and others in the community. Findings include, but are not limited to: 1. Resident 8 moved into the facility in April 2023 with diagnoses including dementia with unspecified psychotic disturbance. Resident 8's most recent "individualized service plan report"(s), which provided a summary of services for the resident, dated 06/22/23 and 07/14/23, and progress notes dated 07/01/23 through 09/08/23 were reviewed. Staff documented daily and on each shift if a behavior was observed. The following behaviors were documented: * Physical aggression such as grabbing, slapping, hitting, and punching staff; * Verbal aggression which included yelling and cussing toward staff and residents; * Resistive to care when providing bathing, personal hygiene, oral care, incontinent care, and wound care; * Wandering into other resident rooms; and * Urinating on other residents' property. The 06/22/23 "Service Plan Report" had nothing documented under behaviors. The 07/14/23 "Service Plan Report" noted "assess and anticipate [residents name] needs, under the section "behavior/mood".  The service plan reports failed to include the following: * A description of the resident's behaviors (as noted above); and * Resident specific interventions or approaches for staff to utilize for each type of behavior. There were no temporary service plans available. The facility failed to evaluate the resident's behaviors and updated the service plan. Resident 8 continued to have behaviors that negatively impacted him/herself and others in the community. On 09/11/23, the need to ensure behaviors were evaluated and the service plan to address behaviors which negatively impacted the resident and others in the community was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant). The findings were acknowledged. Based on interview and record review, it was determined the facility failed to ensure resident behaviors which negatively impacted themselves or others were evaluated and included in the service plan for 2 of 3 sampled residents (#s 2 and 8). Resident 8 repeatedly exhibited verbal and physically aggressive behaviors that negatively impacted him/herself and others in the community. Findings include, but are not limited to:”

“Based on observation and interview, it was determined the facility failed to ensure doors to the secure outdoor recreation area were unlocked unless it was during the nighttime or during severe weather, and failed to have a written policy. Findings include, but are not limited to: During an environmental tour of the facility on 09/05/23 at 9:52 am, the interior "Park" courtyard door in the Columbia Neighborhood was locked. The weather was currently sunny with no precipitation. During an interview and tour of the facility on 09/05/23 at 1:00 pm, with Staff 1 (ED), the interior "Park" courtyard door was observed to be locked. The surveyor requested a copy of the facility's written policy for when the interior courtyard doors would be locked. On 09/08/23 at 11:06 am, the interior "Park" courtyard door in the Sandy Neighborhood was observed to be locked. On 09/08/23 at 11:23 am, the surveyor reported to Staff 1 that the interior "Park" courtyard door continued to be locked. The surveyor requested the facility's written policy. Staff 1 acknowledged and stated she would provide a policy. As of the survey, no policy was given to the survey team. The need to ensure the facility had a written policy for when the secured courtyard doors would be locked was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. No further information was provided. Based on observation and interview, it was determined the facility failed to ensure doors to the secure outdoor recreation area were unlocked unless it was during the nighttime or during severe weather, and failed to have a written policy. Findings include, but are not limited to: During an environmental tour of the facility on 09/05/23 at 9:52 am, the interior "Park" courtyard door in the Columbia Neighborhood was locked. The weather was currently sunny with no precipitation. During an interview and tour of the facility on 09/05/23 at 1:00 pm, with Staff 1 (ED), the interior "Park" courtyard door was observed to be locked. The surveyor requested a copy of the facility's written policy for when the interior courtyard doors would be locked. On 09/08/23 at 11:06 am, the interior "Park" courtyard door in the Sandy Neighborhood was observed to be locked. On 09/08/23 at 11:23 am, the surveyor reported to Staff 1 that the interior "Park" courtyard door continued to be locked. The surveyor requested the facility's written policy. Staff 1 acknowledged and stated she would provide a policy. As of the survey, no policy was given to the survey team. The need to ensure the facility had a written policy for when the secured courtyard doors would be locked was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. No further information was provided. Outside consultant will create a policy for managing out door coutyard doors. Outside consultant or designee will do a weekly random audit at random time to ensure the policy is being followed. Outside consultant or designee will bring the results of the audit to QAPI for 3 months or until the deficient practice is resolved. Outside consultant will create a policy for managing out door coutyard doors. Outside consultant or designee will do a weekly random audit at random time to ensure the policy is being followed. Outside consultant or designee will bring the results of the audit to QAPI for 3 months or until the deficient practice is resolved. There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to ensure the outside perimeter fence gate allowed for egress in the event of an emergency. Findings include, but are not limited to: The facility's outdoor areas were toured on 09/05/23. A perimeter fence gate between the outer "Garden" patio and surrounding property at the back of the building was observed to have a keypad locking device. On 09/05/23 at 12:00 pm, Staff 4 (Maintenance Director) reported, "all egress doors should disengage, but I haven't done a fire drill yet, so I can't say for sure that they do." On 09/05/23 at 12:30 pm, Staff 18 (CG) and Staff 24 (CG) reported they were not aware if the gate unlocked during an emergency or if they needed to enter a code on the keypad. Additionally, Staff 18 and 24 were unable to recall what the keypad code was. The need to ensure the outside perimeter fence gate allowed for egress in the event of an emergency was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure the outside perimeter fence gate allowed for egress in the event of an emergency. Findings include, but are not limited to: The facility's outdoor areas were toured on 09/05/23. A perimeter fence gate between the outer "Garden" patio and surrounding property at the back of the building was observed to have a keypad locking device. On 09/05/23 at 12:00 pm, Staff 4 (Maintenance Director) reported, "all egress doors should disengage, but I haven't done a fire drill yet, so I can't say for sure that they do." On 09/05/23 at 12:30 pm, Staff 18 (CG) and Staff 24 (CG) reported they were not aware if the gate unlocked during an emergency or if they needed to enter a code on the keypad. Additionally, Staff 18 and 24 were unable to recall what the keypad code was. The need to ensure the outside perimeter fence gate allowed for egress in the event of an emergency was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. The code to the key pad of the outside egress gate was posted by the front desk staff. The Maintance Director or the designee will complete a fire drill to ensure that the Egress door disenages properly. Maintance Director or designee will complete a walk- through audit weely to ensure all posted codes are in place to exit doors or gates. MaintenaDce director or designee will bring the audits to QAPI for 3 months or until the deficient practice is resolved. The code to the key pad of the outside egress gate was posted by the front desk staff. The Maintance Director or the designee will complete a fire drill to ensure that the Egress door disenages properly. Maintance Director or designee will complete a walk- through audit weely to ensure all posted codes are in place to exit doors or gates. MaintenaDce director or designee will bring the audits to QAPI for 3 months or until the deficient practice is resolved. There are no detail notes for this visit.”

“The findings of the on-site investigation, conducted 08/30/23 through 08/31/23 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 08/30/23 through 08/31/23 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 observation, interview and record review during an onsite visit 08/30/23 through 08/31/23, it was confirmed the facility failed to implement policies and procedures to assure the prevention and appropriate response to any incident for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to: 1. On 08/30/23 at approximately 4:30 pm, a resident to resident physical altercation was observed between two unsampled residents. There were no staff present immediately on the floor to intervene. A staff member separated the residents after two minutes. On 08/31/23 Staff 13 (Administrator) stated there was no documentation of the above incident, no investigation had been initiated and she was unaware it occurred.  The Compliance Specialist notified Staff 13 on 08/31/23 that an investigation needed to be completed and the incident reported to APS. The CS reported the event to APS. 2. During interview on 08/30/23, Staff 6 (Care Partner) and Staff 7 (Care Partner) stated another Care Partner had been rough with a resident, gave the resident a cold bed bath, and scrubbed the resident's genitalia, arms and mouth rough during the bed bath. Staff 6 and 7 stated they reported the event to the facility's staffing director the previous week and reported it to Staff 2 (Executive Director) and Staff 8 (Consultant) on 08/30/23. On 08/31/23, Staff 13 (Administrator) stated there was no evidence that an investigation had been initiated on this concern or that it was reported to APS. 3. A review of progress notes for Resident 1 and Resident 2 dated 07/01/23 through 08/31/23 revealed the following: * 07/07/23 Care staff reported to LPN that Resident 1 has been having sexual behaviors towards other males on the unit including touching, massaging and kissing. *07/09/23 Resident 1 found in Resident 2's room helping him lay down in bed; *07/12/23 Resident 2 found in Resident 1's room with pants off; *07/12/23 Resident 1 was seen touching and rubbing Resident 2's shoulders *07/13/23 Resident 1 was seen walking with Resident 2 and followed another resident into his/her room; *07/18/23 Resident 1 was inviting other residents into his room, holding hands and rubbing their backs; *07/20/23 Resident 1 was seen trying to lure resident 2 into his room and rubbing shoulders; *07/21/23 Resident 1 was seen rubbing Resident 2's back and neck; *07/23/23 Resident 1 was found naked in Resident 2's room; *07/24/23 Resident 1 was seen exhibiting sexual/touchy behavior towards an unsampled resident; *07/25/23 Resident 1 was seen touching an unsampled resident and holding Resident 2's hand; *07/26/23 Resident 1 was seen rubbing an unsampled resident's head, neck and back; *07/28/23 Resident 1 was seen touching an unsampled resident's back and neck; *07/28/23 Resident 1 found in Resident 2's room. Resident stated he was "helping him get cleaned up"; *08/01/23 Resident was seen guiding Resident 2 back to Resident 1's room; *08/05/23 Resident 1 found kissing Resident 2; *08/09/23 Resident 1 found grabbing Resident 2's hand and attempting to get Resident 2 to walk down the hall; *08/11/23 Resident 1 found holding hands with an unsampled resident. The unsampled resident became agitated and attempted to grab at Resident 1. Resident 1 then attempted to strike unsampled resident; and *08/14/23 Resident 1 was moved into a different part of the community. There was no evidence the facility initiated any investigations into the above events or initiated any interventions to prevent those incidences. Progress notes repeatedly indicated residents were redirected and monitored. Resident 2's current service plan noted s/he has a "significant history of mental/emotional trauma which can present itself as paranoia, fear of sexual harm or sexual inappropriateness of others." During an interview on 08/30/23, Staff 3 (Care Partner/MT) stated if Resident 1 was sexually aggressive with another resident, they would separate them, help them get dressed if needed. S/he further stated they didn't know what to do to prevent the behaviors, just to monitor and redirect. The findings were reviewed with and acknowledged by Staff 13 on 08/31/23. The facility failed to investigate Resident 1's sexual behaviors towards other residents, place interventions for staff to follow and to protect other residents from sexual abuse. Verbal plan of correction: Administrator to be present on shift to shift meetings and ask probing questions regarding residents behaviors. Administrator will review charting every day and follow up with staff members daily, ask and verify what staff did in response to incidents, and confirm interventions are in place. Compliant Specialist provided Oregon Department of Human Services Abuse Investigation and Reporting Guide to the Administrator. Based on observation, interview and record review during an onsite visit 08/30/23 through 08/31/23, it was confirmed the facility failed to implement policies and procedures to assure the prevention and appropriate response to any incident for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:”

“Based on interview and record review, conducted during an onsite visit on 08/30/23 through 08/31/23, the facility failed to develop a service plan that is reflective of the resident's needs for 1 of 1 sampled residents (# 1). Findings include, but are not limited to: 1. A review of progress notes for Resident 1, dated 07/01/23 through 08/31/23 revealed the following: * 07/07/23 Care staff reported to LPN that Resident 1 has been having sexual behaviors towards other males on the unit including touching, massaging and kissing. *07/09/23 Resident 1 found in Resident 2's room helping him lay down in bed; *07/12/23 Resident 2 found in Resident 1's room with pants off; *07/12/23 Resident 1 was seen touching and rubbing Resident 2's shoulders *07/13/23 Resident 1 was seen walking with Resident 2 and followed another resident into his/her room; *07/18/23 Resident 1 was inviting other residents into his room, holding hands and rubbing their backs; *07/20/23 Resident 1 was seen trying to lure resident 2 into his room and rubbing shoulders; *07/21/23 Resident 1 was seen rubbing Resident 2's back and neck; *07/23/23 Resident 1 was found naked in Resident 2's room; *07/24/23 Resident 1 was seen exhibiting sexual/touchy behavior towards an unsampled resident; *07/25/23 Resident 1 was seen touching an unsampled resident and holding Resident 2's hand; *07/26/23 Resident 1 was seen rubbing an unsampled resident's head, neck and back; *07/28/23 Resident 1 was seen touching an unsampled resident's back and neck; *07/28/23 Resident 1 found in Resident 2's room. Resident stated he was "helping him get cleaned up"; *08/01/23 Resident was seen guiding Resident 2 back to Resident 1's room; *08/05/23 Resident 1 found kissing Resident 2; *08/09/23 Resident 1 found grabbing Resident 2's hand and attempting to get Resident 2 to walk down the hall; *08/11/23 Resident 1 found holding hands with an unsampled resident. The unsampled resident became agitated and attempted to grab at Resident 1. Resident 1 then attempted to strike unsampled resident; and *08/14/23 Resident 1 was moved into a different part of the community. A review of Resident 1's current service plan did not indicate the resident had sexual behaviors nor did it include any behavior interventions. During an interview on 08/31/23 Staff 13 (Administrator) stated they had a service planning meeting for Resident 1 on 08/28/23 and would be updating his/her service plan by the end of the day. The findings were reviewed and acknowledged by Staff 13 on 08/31/23. The facility failed to develop a service plan that revealed the resident had behaviors and develop interventions for staff to implement. Verbal plan of Correction: The facility had scheduled every required care conference for the next two weeks. The new Resident Care Coordinator would be starting on 09/05/23. Resident 1's service plan to be updated on 08/31/23. Based on interview and record review, conducted during an onsite visit on 08/30/23 through 08/31/23, the facility failed to develop a service plan that is reflective of the resident's needs for 1 of 1 sampled residents (# 1). Findings include, but are not limited to:”

“Based on interview and record review, conducted during a site visit on 08/30/23 through 08/31/23, it was confirmed the facility failed to carry 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 physician orders, dated 06/15/23 revealed the resident received Rivoraxaban (blood thinning medication) 20 mg oral tablet take 20 mg once daily with dinner. A review of Resident 3's 06/01/23 though 07/31/23 MAR and progress notes revealed this medication was not given until 07/05/23. During an interview 08/30/23, Staff 2 stated the Rivoraxaban had been added incorrectly into the MAR when Resident 3 was admitted and was not visible to the MTs to administer the medication. The findings were reviewed with and acknowledged by Staff 13 (Administrator) on 08/31/23. The facility failed to carry out medication orders as prescribed. Verbal Plan of correction: Pharmacy integration between Consensus and Point Click Care happened in July 2023. MTs receive orders,scan to Consonus and then facility should triple check by RCC and then LPN or RN. Staff 13 will reach out to Integrated Staffing agency on 08/31/23 for nursing needs until a new nurse is onboarded to verify if there are medication errors. Based on interview and record review, conducted during a site visit on 08/30/23 through 08/31/23, it was confirmed the facility failed to carry 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 physician orders, dated 06/15/23 revealed the resident received Rivoraxaban (blood thinning medication) 20 mg oral tablet take 20 mg once daily with dinner. A review of Resident 3's 06/01/23 though 07/31/23 MAR and progress notes revealed this medication was not given until 07/05/23. During an interview 08/30/23, Staff 2 stated the Rivoraxaban had been added incorrectly into the MAR when Resident 3 was admitted and was not visible to the MTs to administer the medication. The findings were reviewed with and acknowledged by Staff 13 (Administrator) on 08/31/23. The facility failed to carry out medication orders as prescribed. Verbal Plan of correction: Pharmacy integration between Consensus and Point Click Care happened in July 2023. MTs receive orders,scan to Consonus and then facility should triple check by RCC and then LPN or RN. Staff 13 will reach out to Integrated Staffing agency on 08/31/23 for nursing needs until a new nurse is onboarded to verify if there are medication errors.”

“Based on observation, interview and record review, conducted during a site visit from 08/30/23 through 08/31/23, it was confirmed 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 for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to: The facility's posted staffing plan indicated the facility needed 2 MTs' and 5 Care Partners during day shift. During the site visit, 2 MTs' and 4 Care partners were observed working on day shift on 08/30/23 and 08/31/23. 1. A review of Resident 1's service plan revealed the resident required assistance with dressing. Bathing instructions were not included on the service plan. On 08/30/23 and 08/31/23, Resident 1 was observed wearing the same clothes and had not been changed. During an interview, Witness 1 ( Family Member) stated Resident 1 required assistance for showering, but s/he does not believe the resident received showers and there was often fecal matter in his/her underwear. 2. A review of Resident 2's service plan revealed s/he required one to one assistance with meals and oral care assistance every morning. During an observation on 08/31/23, Resident 2 did not receive any assistance with the morning meal. During an interview after the breakfast meal, Staff 14 (caregiver) stated s/he did not provide oral care to Resident 2 or any other residents in the morning because s/he did not have time. 3. During an interview on 08/30/23, Staff 4 (housekeeper) was observed working on the floor and providing care to residents. Staff 4 stated s/he was pulled to the floor for the day because of a Care Partner not showing up that day. Staff 4 stated s/he did not provide any showers that day because she didn't know there were any to complete. A review of the shower schedule revealed that two unsampled residents were to receive showers on day shift. 4. During the site visit on 08/31/23, a physical altercation was observed between two unsampled residents, and no staff were visible on the floor to intervene, but were able to separate the residents after two minutes. The findings were reviewed with  Staff 13 (Administrator) on 08/31/23. 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: Staff 2 (Administrator) contacted Integrated Staffing for staffing needs on 08/30/23. Staff 13 followed up at 9 am on 08/31/23 with Integrated Staffing for additional staffing needs. The facility administration continued efforts to hire staff. The facility administration will conduct audits of all current staff, while agency staff would fills in holes prior to the on-boarding of new staff to ensure proper training. Based on observation, interview and record review, conducted during a site visit from 08/30/23 through 08/31/23, it was confirmed 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 for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to: The facility's posted staffing plan indicated the facility needed 2 MTs' and 5 Care Partners during day shift. During the site visit, 2 MTs' and 4 Care partners were observed working on day shift on 08/30/23 and 08/31/23.”

“Based on observation, interview and record review,  conducted during a site visit on 08/30/23 through 08/31/23, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool for 4 of 4 sampled residents (#s 1, 2, 3 and 5). Findings include, but not limited to: A review of the facility's ABST on 08/30/23 indicated the need for the following staff: Day: 46.1 hours(6.14 staff); Swing: 36.07 hours (4.80 staff); and Noc: 9.3 hours (1.24 staff) The facility's posted staffing plan indicted the facility needed 2 MTs' and 5 Care Partners during day shift. During the site visit, 2 MTs' and 4 Care Partners were observed working on day shift on 08/30/23 and 08/31/23. The facility was not staffed to the level required by their ABST. Observations, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs in the following areas: Resident 1: Dressing; Cueing and redirecting due to cognitive impairment; Time spent monitoring behavioral conditions; Behavior interventions and re-direction; and Bathing. Resident 2: Dressing; Nail care/brushing hair; Bowel and bladder management; Escorting to/from meals; and Meals. Resident 3: toileting; dressing; oral care; and transfers. Resident 5's ABST profile was incomplete. The findings were reviewed with and acknowledged by Staff 13 (Administrator) on 08/31/23. The facility failed to fully implement and update an ABST. Based on observation, interview and record review,  conducted during a site visit on 08/30/23 through 08/31/23, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool for 4 of 4 sampled residents (#s 1, 2, 3 and 5). Findings include, but not limited to: A review of the facility's ABST on 08/30/23 indicated the need for the following staff: Day: 46.1 hours(6.14 staff); Swing: 36.07 hours (4.80 staff); and Noc: 9.3 hours (1.24 staff) The facility's posted staffing plan indicted the facility needed 2 MTs' and 5 Care Partners during day shift. During the site visit, 2 MTs' and 4 Care Partners were observed working on day shift on 08/30/23 and 08/31/23. The facility was not staffed to the level required by their ABST. Observations, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs in the following areas: Resident 1: Dressing; Cueing and redirecting due to cognitive impairment; Time spent monitoring behavioral conditions; Behavior interventions and re-direction; and Bathing. Resident 2: Dressing; Nail care/brushing hair; Bowel and bladder management; Escorting to/from meals; and Meals. Resident 3: toileting; dressing; oral care; and transfers. Resident 5's ABST profile was incomplete. The findings were reviewed with and acknowledged by Staff 13 (Administrator) on 08/31/23. The facility failed to fully implement and update an ABST.”

“Based on observation, interview and record review, conducted during a site visit from 08/30/23 to 08/31/23, it was confirmed the facility failed to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned for 4 of 4  sampled staff members (#s 4, 6, 9 and 10). Findings include, but are not limited to: A review of staff training records for Staff 4 (Housekeeper), Staff 6 (Care Partner), Staff 9 (MT) and Staff 10 (MT) revealed: *There were no training records for Staff 4 and Staff 6; *Staff 9 had completed eight pre-service training provided by Oregon Care Partners; and *Staff 10 completed two Relias trainings on 10/26/22 called "Welcome to Relias" and "Welcome to Relias: The Game Elements Tour". There were no additional training records available for those four staff members including any demonstrated competencies. Staff 4, Staff 6, Staff 9 and Staff 10 were observed working on the floor with residents independently on 08/30/23. During an interview on 08/30/23, Staff 4 stated s/he wasn't sure what his/her title was, but thinks s/he is a care partner, but it was not official yet. S/he further stated s/he was helping on the floor with cares today because a care partner called-out, but s/he normally works as a housekeeper. During an interview with Staff 1 (RN Consultant), Staff 2 (Executive Director) and Staff 8 (Consultant) stated the former RCC was responsible for verifying and tracking staff competencies but s/he quit. During an interview with Staff 6 on 08/30/23, s/he stated s/he was asked to work as a MT on swing shift on 08/30/23 but had never been trained to do this and was nervous. S/he further stated that Staff 8 had told him/her they would get a "crash course" on medications and then could pass medications that night. Staff 6 was observed with keys to the med cart and completed a narcotic count to start the shift. Compliance Specialist intervened for resident safety and asked Staff 2 and Staff 8 to remove Staff 6 from the medication cart, due to not having any training. The findings were reviewed with Staff 13 (Administrator) on 08/31/23. It was confirmed the facility failed to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. Verbal plan of correction: Facility to audit all staff training documents including relias, CPR, food handlers and competencies checklist. Facility will have all staff training documented and up to date within 30 days and will implement a policy and procedure for new hires to complete required trainings prior to starting on the floor. That will be the job on the new RCC who will start 09/05/23. Based on observation, interview and record review, conducted during a site visit from 08/30/23 to 08/31/23, it was confirmed the facility failed to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned for 4 of 4  sampled staff members (#s 4, 6, 9 and 10). Findings include, but are not limited to: A review of staff training records for Staff 4 (Housekeeper), Staff 6 (Care Partner), Staff 9 (MT) and Staff 10 (MT) revealed: *There were no training records for Staff 4 and Staff 6; *Staff 9 had completed eight pre-service training provided by Oregon Care Partners; and *Staff 10 completed two Relias trainings on 10/26/22 called "Welcome to Relias" and "Welcome to Relias: The Game Elements Tour". There were no additional training records available for those four staff members including any demonstrated competencies. Staff 4, Staff 6, Staff 9 and Staff 10 were observed working on the floor with residents independently on 08/30/23. During an interview on 08/30/23, Staff 4 stated s/he wasn't sure what his/her title was, but thinks s/he is a care partner, but it was not official yet. S/he further stated s/he was helping on the floor with cares today because a care partner called-out, but s/he normally works as a housekeeper. During an interview with Staff 1 (RN Consultant), Staff 2 (Executive Director) and Staff 8 (Consultant) stated the former RCC was responsible for verifying and tracking staff competencies but s/he quit. During an interview with Staff 6 on 08/30/23, s/he stated s/he was asked to work as a MT on swing shift on 08/30/23 but had never been trained to do this and was nervous. S/he further stated that Staff 8 had told him/her they would get a "crash course" on medications and then could pass medications that night. Staff 6 was observed with keys to the med cart and completed a narcotic count to start the shift. Compliance Specialist intervened for resident safety and asked Staff 2 and Staff 8 to remove Staff 6 from the medication cart, due to not having any training. The findings were reviewed with Staff 13 (Administrator) on 08/31/23. It was confirmed the facility failed to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. Verbal plan of correction: Facility to audit all staff training documents including relias, CPR, food handlers and competencies checklist. Facility will have all staff training documented and up to date within 30 days and will implement a policy and procedure for new hires to complete required trainings prior to starting on the floor. That will be the job on the new RCC who will start 09/05/23.”