Fircrest Senior Living.

“Based on observation, interview, and record review, it was determined the facility failed to ensure residents' right to be treated with dignity and respect for 1 of  2 sampled residents and two unsampled residents who received meal assistance and ADL care, and to receive services in a manner that protected privacy and dignity for 1 of 1 sampled resident (#8) who received care at bedside. Findings include, but are not limited to: 1. Meal service observations were made during the survey on 09/24/24. On 09/24/24 at 12:12 pm, meal observations were conducted in the facility's activities room, which served as a secondary dining area. Resident 8 and three unsampled residents were receiving meal assistance from Staff 8 (CG) and Staff 9 (CG). During the meal service, and while providing direct care to the residents, Staff 8 and Staff 9 continuously spoke to each other in a language other than which the residents could understand. The need to ensure residents' right to be treated with dignity and respect was discussed with Staff 1 (ED) and Staff 2 (LPN, Residential Services Coordinator) on 09/25/24. They acknowledge the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure residents' right to be treated with dignity and respect for 1 of  2 sampled residents and two unsampled residents who received meal assistance and ADL care, and to receive services in a manner that protected privacy and dignity for 1 of 1 sampled resident (#8) who received care at bedside. Findings include, but are not limited to:”

“The findings of the re-licensure survey, conducted 07/08/24 through 07/11/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the re-licensure survey, conducted 07/08/24 through 07/11/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the first revisit to the re-licensure survey of 07/11/24, conducted 09/23/24  through 09/25/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the first revisit to the re-licensure survey of 07/11/24, conducted 09/23/24  through 09/25/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the second revisit to the re-licensure survey of 07/11/24, conducted 12/30/24 through 12/31/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the second revisit to the re-licensure survey of 07/11/24, conducted 12/30/24 through 12/31/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the third revisit to the relicensure survey of 07/11/24, conducted 03/11/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations. The findings of the third revisit to the relicensure survey of 07/11/24, conducted 03/11/25, are documented in this report. It was d”

“Based on interview and record review, it was determined the facility failed to ensure any incident of abuse or suspected abuse was reported to the local SPD office or the local AAA, promptly investigated all reports of abuse and suspected abuse and took measures necessary to protect residents and prevent the reoccurrence of abuse for 1 of 1 sampled resident (#10) who incidents were reviewed. Findings include, but are not limited to: Resident 10 was admitted to the facility in 09/2024 with diagnoses including bilateral osteoarthritis of knee, psychotic disturbance, and dementia. The resident's 09/20/24 service plan, 09/09/24 through 09/24/24 progress notes, an incident report, and Temporary Service Plans (TSP)'s were reviewed, and observations and interviews were conducted. The facility failed to immediately report abuse or suspected abuse to the local SPD office and promptly investigate all reports of abuse and suspected abuse for the following incident: 09/09/24 - Progress notes indicated Resident 10 was sitting on the couch in another resident's room when the Activity Director entered with one of the residents who occupied that room. When s/he was asked "politely" by staff to leave, Resident 10 began yelling and knocked the staff to the floor. "The other resident in the living room tried to intervene by yelling at [him/her] to stop before [Resident 10] got up in [his/her] face as well [sic] threatening to do something about [him/her] next." On 09/25/24 at 10:35 am, an interview with Staff 1 (ED) indicated she was not working at the time and confirmed the incident was not reported to the local SPD office. On 09/25/24 at 10:45 am, an interview with Staff 2 (LPN/Resident Services Coordinator), who was covering at the time, confirmed there was no investigation and he had not completed "a TSP because by the time I got there the residents had been separated out of that room", Resident 10's spouse got him/her to leave the room "and [Resident 10] was fine". The need to ensure all incidents of abuse were immediately reported to the local SPD office and investigated was discussed with Staff 1 and Staff 2 on 09/25/24 at 12:00 pm. They acknowledged the findings. On 09/25/24, survey requested the facility report the incident to the local SPD office, verification was received prior to exit. Based on interview and record review, it was determined the facility failed to ensure any incident of abuse or suspected abuse was reported to the local SPD office or the local AAA, promptly investigated all reports of abuse and suspected abuse and took measures necessary to protect residents and prevent the reoccurrence of abuse for 1 of 1 sampled resident (#10) who incidents were reviewed. Findings include, but are not limited to: Resident 10 was admitted to the facility in 09/2024 with diagnoses including bilateral osteoarthritis of knee, psychotic disturbance, and dementia. The resident's 09/20/24 service plan, 09/09/24 through 09/24/24 progress notes, an incident report, and Temporary Service Plans (TSP)'s were reviewed, and observations and interviews were conducted. The facility failed to immediately report abuse or suspected abuse to the local SPD office and promptly investigate all reports of abuse and suspected abuse for the following incident: 09/09/24 - Progress notes indicated Resident 10 was sitting on the couch in another resident's room when the Activity Director entered with one of the residents who occupied that room. When s/he was asked "politely" by staff to leave, Resident 10 began yelling and knocked the staff to the floor. "The other resident in the living room tried to intervene by yelling at [him/her] to stop before [Resident 10] got up in [his/her] face as well [sic] threatening to do something about [him/her] next." On 09/25/24 at 10:35 am, an interview with Staff 1 (ED) indicated she was not working at the time and confirmed the incident was not reported to the local SPD office. On 09/25/24 at 10:45 am, an interview with Staff 2 (LPN/Resident Services Coordinator), who was covering at the time, confirmed there was no investigation and he had not completed "a TSP because by the time I got there the residents had been separated out of that room", Resident 10's spouse got him/her to leave the room "and [Resident 10] was fine". The need to ensure all incidents of abuse were immediately reported to the local SPD office and investigated was discussed with Staff 1 and Staff 2 on 09/25/24 at 12:00 pm. They acknowledged the findings. On 09/25/24, survey requested the facility report the incident to the local SPD office, verification was received prior to exit.”

“Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#7) whose evaluation was reviewed. Findings include, but are not limited to: Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia. The Move-In Evaluation, dated 03/29/24, was reviewed and revealed missing information in the following required elements: * Customary routines regarding sleeping, eating, and bathing; * List of medications and PRN use; * Personality including how the person copes with change or challenging situations; * Ability to understand and be understood; * Non-pharmaceutical interventions for pain; * Nutrition habits, fluid preferences, and weight if indicated; and * Complex medication regimen. The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (ED) on 07/10/24. She acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#7) whose evaluation was reviewed. Findings include, but are not limited to: Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia. The Move-In Evaluation, dated 03/29/24, was reviewed and revealed missing information in the following required elements: * Customary routines regarding sleeping, eating, and bathing; * List of medications and PRN use; * Personality including how the person copes with change or challenging situations; * Ability to understand and be understood; * Non-pharmaceutical interventions for pain; * Nutrition habits, fluid preferences, and weight if indicated; and * Complex medication regimen. The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (ED) on 07/10/24. She acknowledged the findings. The facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#7) whose evaluation was reviewed. 1. Current evaluation was updated with the missing information. 2. In the future, we will be using the resident review form for all new move-ins to ensure that all of the required elements are met. 3. This will be reviewed by both the RN and LPN at time of move-in and at 30-day review. Executive Director or designee will audit all new admissions weekly for a period of three months to ensure all required elements were addressed. 4. The Executive Director and RN will be responsible to ensure these corrections are completed and monitored. The facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#7) whose evaluation was reviewed.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 2 of 5 sampled residents (#s 3 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 11/2017 with diagnoses including dementia. The resident's service plan, dated 06/26/24, and Temporary Service Plans were reviewed. Resident 3 was observed and staff were interviewed. The service plan lacked information relating to the resident's current needs and/or clear caregiving instruction in the following areas: * Ability to take self to the restroom; * Interventions when the resident yelled at the roommate; * How Resident 3 communicated when other residents were getting too close to him/her; * Changing staff members when the resident was reluctant to receiving care; * Ability to get self ready for bed; and * Where the resident preferred to eat their meals. The need to ensure service plans were reflective of the resident's current needs and provided clear caregiving instruction was discussed with Staff 1 (ED) and Staff 3 (Lead MT) on 07/11/24. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 02/2023 with diagnoses including dementia. The resident's service plan, dated 06/24/24, Temporary Service Plans and progress notes, dated 04/09/24 through 07/05/24, were reviewed. The resident was observed and staff were interviewed. The service plan lacked information relating to the resident's current needs and/or clear caregiving instruction in the following areas: * Apartment door alarm; * Hearing; and * Toileting assistance. The need to ensure service plans were reflective of the resident's current needs and provided clear caregiving instruction was discussed with Staff 1 (ED) and Staff 3 (Lead MT) on 07/11/24. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 2 of 5 sampled residents (#s 3 and 6) whose service plans were reviewed. Findings include, but are not limited to:”

“Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 1 of 1 sampled resident (#8) who was observed receiving ADL care at bedside and meal assistance. Findings include, but are not limited to: Resident 8 was admitted to the facility in 04/2023 with diagnoses including dementia. The current service plan, dated 09/23/24, identified the resident had the following care needs: * Feeding assistance from staff; * Two-person assist for transfers using a hoyer lift; and * Full assist with toileting and perineal care. a. On 09/24/24, meal observations were conducted in the facility's activities room, which served as a secondary dining area. At 12:16 pm, Staff 9 was observed handling a resident's soiled plate with the thumb of her ungloved left hand on the surface of the plate. When she returned the plate to the table, she picked up the resident's used cup with the ungloved left hand, placing her fingers near the rim of the cup. After Staff 9 returned the cup to the resident, she sat next to Resident 8, picked up a napkin with the ungloved left hand and began wiping Resident 8's mouth with the napkin. Staff 9 was not observed to have preformed hand hygiene after handling the soiled dishware and prior to assisting Resident 8. On 09/25/24, the need to ensure staff used universal precautions when providing care to residents was discussed with Staff 1 (ED) and Staff 2 (LPN, Residential Services Coordinator). They acknowledged the findings. Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 1 of 1 sampled resident (#8) who was observed receiving ADL care at bedside and meal assistance. Findings include, but are not limited to: Resident 8 was admitted to the facility in 04/2023 with diagnoses including dementia. The current service plan, dated 09/23/24, identified the resident had the following care needs: * Feeding assistance from staff; * Two-person assist for transfers using a hoyer lift; and * Full assist with toileting and perineal care. a. On 09/24/24, meal observations were conducted in the facility's activities room, which served as a secondary dining area. At 12:16 pm, Staff 9 was observed handling a resident's soiled plate with the thumb of her ungloved left hand on the surface of the plate. When she returned the plate to the table, she picked up the resident's used cup with the ungloved left hand, placing her fingers near the rim of the cup. After Staff 9 returned the cup to the resident, she sat next to Resident 8, picked up a napkin with the ungloved left hand and began wiping Resident 8's mouth with the napkin. Staff 9 was not observed to have preformed hand hygiene after handling the soiled dishware and prior to assisting Resident 8. On 09/25/24, the need to ensure staff used universal precautions when providing care to residents was discussed with Staff 1 (ED) and Staff 2 (LPN, Residential Services Coordinator). They acknowledged the findings. b. During an ADL observation with Resident 8 on 09/24/24 at 11:05 am, the following was observed: * Three caregiving staff donned gloves and assisted the resident with incontinence care, which included physical assistance with rolling, perineal care, and repositioning; * All three staff assisted in removing the soiled brief; * One staff provided perineal care that included using wipes. All three staff then touched a clean incontinence brief, the resident's legs and torso, clothing, heel protectors, the bedding, and the hoyer sling, all while wearing the soiled gloves; * The staff who cleaned the perineal area then used the controls of the hoyer lift while the other two staff touched the handles, back and footplate's of the wheelchair; and * The staff who cleaned the perineal area removed the soiled gloves and performed hand hygiene prior to leaving the resident's room. The other two staff remained in the room and made the resident's bed and assisted Resident 8's roommate who was also in the room without changing soiled gloves. The need to maintain effective infection prevention and control while providing ADL care was reviewed with Staff 1 (ED), Staff 2 (LPN/Resident Services Coordinator) and Staff 3 (Lead MT) on 09/25/24 at 12:00 pm. They acknowledged the findings. b. During an ADL observation with Resident 8 on 09/24/24 at 11:05 am, the following was observed: * Three caregiving staff donned gloves and assisted the resident with incontinence care, which included physical assistance with rolling, perineal care, and repositioning; * All three staff assisted in removing the soiled brief; * One staff provided perineal care that included using wipes. All three staff then touched a clean incontinence brief, the resident's legs and torso, clothing, heel protectors, the bedding, and the hoyer sling, all while wearing the soiled gloves; * The staff who cleaned the perineal area then used the controls of the hoyer lift while the other two staff touched the handles, back and footplate's of the wheelchair; and * The staff who cleaned the perineal area removed the soiled gloves and performed hand hygiene prior to leaving the resident's room. The other two staff remained in the room and made the resident's bed and assisted Resident 8's roommate who was also in the room without changing soiled gloves. The need to maintain effective infection prevention and control while providing ADL care was reviewed with Staff 1 (ED), Staff 2 (LPN/Resident Services Coordinator) and Staff 3 (Lead MT) on 09/25/24 at 12:00 pm. They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure a system was in place to track controlled substances for 1 of 1 sampled resident (#4) who was administered prescribed PRN narcotic medication. Findings include, but are not limited to: Resident 4 was admitted to the facility in 07/2023 with diagnoses including dementia and chronic obstructive pulmonary disease. The resident's 06/01/24 through 07/08/24 MARs and physician orders were reviewed. The following was identified: * The resident had a physician order for Hydrocod/APAP 5/325 mg tab, one tablet every six hours as needed for severe pain. * The 06/01/24 through 07/08/24 MAR revealed the resident was administered the PRN narcotic on 31 occasions in 06/2024 and on nine occasions between 07/01/24 and 07/08/24. * The Controlled Substance Distribution log contained nine entries for 06/2024 and five entries for 07/2024, which were not reflected on the MARs. * The number of tablets remaining noted in the Controlled Substance Distribution log matched the number of tablets remaining on the corresponding medication cards. The need to ensure a system was in place for tracking controlled substances was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (Lead MT) on 07/11/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure a system was in place to track controlled substances for 1 of 1 sampled resident (#4) who was administered prescribed PRN narcotic medication. Findings include, but are not limited to: Resident 4 was admitted to the facility in 07/2023 with diagnoses including dementia and chronic obstructive pulmonary disease. The resident's 06/01/24 through 07/08/24 MARs and physician orders were reviewed. The following was identified: * The resident had a physician order for Hydrocod/APAP 5/325 mg tab, one tablet every six hours as needed for severe pain. * The 06/01/24 through 07/08/24 MAR revealed the resident was administered the PRN narcotic on 31 occasions in 06/2024 and on nine occasions between 07/01/24 and 07/08/24. * The Controlled Substance Distribution log contained nine entries for 06/2024 and five entries for 07/2024, which were not reflected on the MARs. * The number of tablets remaining noted in the Controlled Substance Distribution log matched the number of tablets remaining on the corresponding medication cards. The need to ensure a system was in place for tracking controlled substances was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (Lead MT) on 07/11/24. They acknowledged the findings. The facility failed to ensure a system was in place to track controlled substances for 1 of 1 sampled resident (#4) who was administered prescribed PRN narcotic medication. 1. All controlled substances distribution logs have been audited and any discrepencies have been documented and entered in to the MAR. 2. Retraining will be completed with all current med techs and new med techs prior to working on the med cart to ensure that they are aware of the policy and are documenting correctly. 3. Audits of the controlled substance distribution logs to the MAR will be completed weekly by the Resident Service Coordinator and/or the Lead Med Tech. Any discrepencies will be reported to the RN and Executive Director. RN will perform random audits of the CS logs 2x/month for three months to ensure staff are following the policy and procedure. 4. The RN will be responsible to ensure that these corrections are completed/monitored. The facility failed to ensure a system was in place to track controlled substances for 1 of 1 sampled resident (#4) who was administered prescribed PRN narcotic medication.”

“Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a physician or other legally recognized prescriber for 2 of 4 sampled residents (#s 5 and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 06/2021 with diagnoses including dementia. The resident's 06/01/24 through 07/08/24 MARs were reviewed. The following was identified: * On 06/26/24 there were seven medications which were not initial as administered at 8:00 pm. There was no indication whether or not the medication had been administered. In an interview on 07/11/24 at 9:35 am, Staff 1 (ED) and Staff 3 (Lead MT) stated it was "probably" the MT working that shift "got busy" and neglected to enter the administration time in the electronic MAR. The need to ensure all medication administered to residents was documented accurately in the MAR was discussed with Staff 1 and Staff 2 on 07/11/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a physician or other legally recognized prescriber for 2 of 4 sampled residents (#s 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC) and failed to ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Review of fire drill and fire and life safety records for 01/2024 through 07/2024 identified the following: a. The fire drill records lacked documentation of the following components: * Location of simulated fire origin; * Escape route used; and * Problems encountered. b. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills and the content of the training was related to fire and life safety. On 07/11/24, the need to ensure all required components of fire drills were documented and fire and life safety instruction to staff was provided on alternate months was discussed with Staff 1 (ED) and Staff 3 (Lead MT). They acknowledged the findings. Based on interview and record review, it was determined the facility failed to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC) and failed to ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Review of fire drill and fire and life safety records for 01/2024 through 07/2024 identified the following: a. The fire drill records lacked documentation of the following components: * Location of simulated fire origin; * Escape route used; and * Problems encountered. b. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills and the content of the training was related to fire and life safety. On 07/11/24, the need to ensure all required components of fire drills were documented and fire and life safety instruction to staff was provided on alternate months was discussed with Staff 1 (ED) and Staff 3 (Lead MT). They acknowledged the findings. The facility failed to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC) and failed to ensure fire and life safety instruction was provided to staff on alternate months. 1. Fire Drill records identified were updated to include missing information from drills conducted. 2. Retraining was completed with the Environmental Services Director. 3. Fire Drills are scheduled every other month and will be conducted by Exec. Director and Environmental Services Director. Fire and Life Safety education will be completed on alternate months and clearly documented. The Executive Director will track all Fire Drill and Fire and Life Safety education documentation to ensure it is complete. 4. The Executive Director will be responsible for ensuring this is completed. The facility failed to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC) and failed to ensure fire and life safety instruction was provided to staff on alternate months.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C260. Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C260. Refer to C260 Refer to C260 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. This is a repeat citation. Findings include but are not limited to: Refer to C231, C260, and C295. 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. This is a repeat citation. Findings include but are not limited to: Refer to C231, C260, and C295. See C231, C260, C295 See C231, C260, C295 There are no detail notes for this visit.”

“Based on 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 420. Based on 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 420. See POC C 420. See POC C 420. 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 C200, C231, and C295. 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 C200, C231, and C295. Refer to C200, C231 and C295 Refer to C200, C231 and C295 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 and C295. 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 and C295. See C231 and C295 See C231 and C295 There are no detail notes for this visit.”

“Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 302, and C 310. Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 302, and C 310. See POC C 252, C 260, C 302 and C 310. See POC C 252, C 260, C 302 and C 310. 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. 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. Refer C260 Refer C260 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. 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. See C260 See C260 There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 6) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3, 5, and 6's current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident. The need to develop a daily meal program based on the resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (ED) and Staff 3 (Lead MT) on 07/11/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 6) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3, 5, and 6's current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident. The need to develop a daily meal program based on the resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (ED) and Staff 3 (Lead MT) on 07/11/24. They acknowledged the findings. The facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 6) whose nutrition and hydration plans were reviewed. 1. All identified resident service plans were updated to give information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the residents.  A daily meal program based on resident preferences was included in their service plans. 2. All resident service plans will be reviewed and updated to reflect their individualized nutrition and hydration status, preferences and needs. 3. This will be evaluated at every service plan meeting including move-in, 30-day, quarterly and as needed. The RN or designee will audit five service plans weekly for a period of three months to ensure appropriate, individualized nutrition and hydration preferences and plans are outlined in the service plan. 4. The Executive Director and RN will be responsible for ensuring this is completed and monitored. The facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 6) whose nutrition and hydration plans were reviewed.”