Fircrest Senior Living.

“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 07/22/25 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas: * Interior of ice maker – build up of pink matter; * Exterior doors and vents below doors, lower interior shelves of freezers and refrigerators – smears/food drips/debris/dried and/or frozen food spills; * Upper shelves above two and three compartment sinks – debris/dust build up; * Splash guard on commercial stand mixer – food splatter; * Commercial can opener blade – food debris; * Lower shelf containing mixer bowl and attachments – debris/spills; * Food bin lids in dry food storage – food debris build up; * Operating window air conditioner - dusty; * Sides of stove – drips/spills; * Area below oven door – build up of black matter/grease; * Lower shelf next to stove – debris/grease/dust; * Fan operating next to service line – dusty; * Cabinet door exteriors and door tracks on front side of service line – drips/spills/debris; * Interior lower shelf of cabinet containing syrup, cereal, brown sugar, sauces – spills; * Flooring and piping under dishwashing area – significant build up of black matter/dust; * Wall behind dishwashing machine – build up of black/brown matter; and * Top of dishwashing machine – build up of dried matter. Improper food storage: * Refrigerator #2 and #4 – open, undated and unlabeled food items (sliced cheese/pink mixture of cottage cheese and fruit/meat patty); and * Dry food storage – multiple food containers with unsecure lids. The areas of concern were observed and discussed with Staff 1 (Dietary Manager) and discussed with Staff 2 (Med Tech), Staff 3 (RDO), Staff 4 (LN) and Staff 5 (ALF Administrator) on 07/22/25. The findings were acknowledged.”

“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, 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.”

“Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/01/22.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: 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 Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/01/22.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: 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, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to implement a policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner within 86 hours. Resident 1 was not referred to the nearest trained sexual assault examiner within 86 hours following a possible sexual assault. Findings include, but are not limited to: An incident report, dated 05/30/24, indicated Resident 1 was found in Resident 2's room undressed, and Resident 2 was in the process of undressing. It further indicated sexual abuse had been ruled out. An email from Staff 2 (LPN) to the Department, dated 06/05/24, indicated "There were no signs of sexual abuse or sexual activity. I performed an assessment on the female resident and found no signs of abuse such as bruising, bleeding, or tearing." During an interview on 06/05/24, Staff 2 (LPN) stated the following: - S/he had performed an evaluation and ruled out sexual abuse; - Staff 2 was not a trained sexual assault examiner; - S/he was unaware of the requirement to refer residents who may be victims of sexual assault the nearest trained sexual assault examiner within 86 hours; and - Resident 1 had not been referred to the nearest sexual assault examiner. An incident report, dated 05/31/24, indicated the following: - Resident 1 had been found in Resident 2's room; - Resident 1 and Resident 2 were unclothed; - Resident 2 was attempting to penetrate Resident 1 sexually; - An assessment had been conducted on Resident 1 and there were "no signs of sexual abuse noted;" and - Resident 1 had "small yellowing bruises on [his/her] right buttock that appeared to be days old." During an interview on 06/05/24, Staff 2 stated s/he had conducted the assessment of Resident 1 on 05/31/24. S/he again stated s/he was not a trained sexual assault examiner. An incident report, dated 06/02/24, indicated that at approximately 5:00 am Resident 1 had been found by a staff member on Resident 3's bed. Resident 1 was fully clothed, while Resident 3 was partially undressed and touching himself sexually over Resident 1. It further indicated "no signs of sexual abuse were noted." In an interview Staff 2 again stated s/he had performed the assessment of Resident 1 on 06/02/24. The facility's "Intimacy/Sexual Intimacy/Sexual Assault" policy indicated "Initial Interventions:  ... Call 911. Report suspicion of acute sexual assault and request transportation via ambulance to the E.R. for examination by a trained Sexual Assault Examiner (SAE)." Resident 1 was observed to be transported by ambulance at approximately 10:22 pm on 06/05/24, approximately 89 hours after the incident on 06/02/24. Staff 2 stated Resident 1 was being transported for a sexual assault assessment. During an interview on 06/06/24, Witness 1 (Hospice RN) stated "No, [Resident 1] can't consent to anything." S/he further stated Resident 1 was incapable of undressing his/herself. Resident 1's service plan, dated 03/12/24, indicated s/he required "care staff to assist [Resident 1] with all undressing and dressing needs," "demonstrates inappropriate judgment, behavior, and ability to function in social settings," and "has severe memory loss." The facility failed to refer Resident 1 to the nearest trained sexual assault examiner within 86 hours, resulting in possible degradation of evidence. LCU requested a safety plan for Residents 1, 2, and 3 on 06/05/24 at approximately 8:30 pm. Safety plans for Residents 1, 2, and 3, were provided by the facility and accepted by LCU at approximately 10:25 pm. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2, Staff 3 (Lead Med Tech), Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President). The Department placed a condition on the facility on 06/07/24. Based on observation, interview, and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to implement a policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner within 86 hours. Resident 1 was not referred to the nearest trained sexual assault examiner within 86 hours following a possible sexual assault. Findings include, but are not limited to: An incident report, dated 05/30/24, indicated Resident 1 was found in Resident 2's room undressed, and Resident 2 was in the process of undressing. It further indicated sexual abuse had been ruled out. An email from Staff 2 (LPN) to the Department, dated 06/05/24, indicated "There were no signs of sexual abuse or sexual activity. I performed an assessment on the female resident and found no signs of abuse such as bruising, bleeding, or tearing." During an interview on 06/05/24, Staff 2 (LPN) stated the following: - S/he had performed an evaluation and ruled out sexual abuse; - Staff 2 was not a trained sexual assault examiner; - S/he was unaware of the requirement to refer residents who may be victims of sexual assault the nearest trained sexual assault examiner within 86 hours; and - Resident 1 had not been referred to the nearest sexual assault examiner. An incident report, dated 05/31/24, indicated the following: - Resident 1 had been found in Resident 2's room; - Resident 1 and Resident 2 were unclothed; - Resident 2 was attempting to penetrate Resident 1 sexually; - An assessment had been conducted on Resident 1 and there were "no signs of sexual abuse noted;" and - Resident 1 had "small yellowing bruises on [his/her] right buttock that appeared to be days old." During an interview on 06/05/24, Staff 2 stated s/he had conducted the assessment of Resident 1 on 05/31/24. S/he again stated s/he was not a trained sexual assault examiner. An incident report, dated 06/02/24, indicated that at approximately 5:00 am Resident 1 had been found by a staff member on Resident 3's bed. Resident 1 was fully clothed, while Resident 3 was partially undressed and touching himself sexually over Resident 1. It further indicated "no signs of sexual abuse were noted." In an interview Staff 2 again stated s/he had performed the assessment of Resident 1 on 06/02/24. The facility's "Intimacy/Sexual Intimacy/Sexual Assault" policy indicated "Initial Interventions:  ... Call 911. Report suspicion of acute sexual assault and request transportation via ambulance to the E.R. for examination by a trained Sexual Assault Examiner (SAE)." Resident 1 was observed to be transported by ambulance at approximately 10:22 pm on 06/05/24, approximately 89 hours after the incident on 06/02/24. Staff 2 stated Resident 1 was being transported for a sexual assault assessment. During an interview on 06/06/24, Witness 1 (Hospice RN) stated "No, [Resident 1] can't consent to anything." S/he further stated Resident 1 was incapable of undressing his/herself. Resident 1's service plan, dated 03/12/24, indicated s/he required "care staff to assist [Resident 1] with all undressing and dressing needs," "demonstrates inappropriate judgment, behavior, and ability to function in social settings," and "has severe memory loss." The facility failed to refer Resident 1 to the nearest trained sexual assault examiner within 86 hours, resulting in possible degradation of evidence. LCU requested a safety plan for Residents 1, 2, and 3 on 06/05/24 at approximately 8:30 pm. Safety plans for Residents 1, 2, and 3, were provided by the facility and accepted by LCU at approximately 10:25 pm. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2, Staff 3 (Lead Med Tech), Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President). The Department placed a condition on the facility on 06/07/24.”

“Based on observation, interview, and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to monitor a resident consistent with his or her evaluated needs and service plan. The facility was to provide one-on-one supervision for the safety of Resident 1 and failed to do so. Findings include, but are not limited to: An incident report, dated 05/30/24, indicated Resident 1 was found in Resident 2's room undressed, and Resident 2 was in the process of undressing. It further indicated sexual abuse had been "ruled out." During an interview on 06/05/24, Staff 2 (LPN) stated Resident 1 had moved rooms. An incident report, dated 05/31/24, indicated the following: - Resident 1 had been found in Resident 2's room; - Resident 1 and Resident 2 were unclothed; - Resident 2 was attempting to penetrate Resident 1 sexually; - An assessment had been conducted on Resident 1 and there were "no signs of sexual abuse noted;" and - Resident 1 had "small yellowing bruises on [his/her] right buttock that appeared to be days old." During an interview on 06/05/24, Staff 2 (LPN) stated Resident 1 had been placed on 15-minute checks on 05/31/24 and placed under 1-on-1 supervision on 06/01/24. S/he further stated the facility RN had not been notified of the incidents on 05/30/24, 05/31/24, 06/02/24, or 06/04/24 as of approximately 6:35 pm on 06/05/24. Fifteen-minute safety check logs for Resident 1 obtained on 06/05/24 were dated 06/02/24 through 06/05/24. There was no prior documented evidence 15-minute safety checks had been implemented for Resident 1. A temporary service plan, dated 06/01/24, indicated Resident 1 "needs to be 1-on-1 with a care staff at all times to ensure [his/her] safety." Staff training documentation for Resident 1's 1-on-1 requirement indicated staff signed the document on 06/05/24. An incident report, dated 06/02/24, indicated that at approximately 5:00 am Resident 1 had been found by staff on Resident 3's bed. Resident 1 was fully clothed, while Resident 3 was partially undressed and touching his/herself sexually over Resident 1. It further indicated "no signs of sexual abuse were noted." In an interview on 06/05/24, Staff 3 (Lead Med Tech) stated the employee that was supposed to be doing the 1-on-1 had been suspended. S/he further stated the 15-minute safety check log had been started on 06/02/24 and the 1-on-1 supervision had been in place before 06/02/24. An incident report, dated 06/04/24, indicated Resident 1 had been found cornered by Resident 3, in Resident 3's shower, with his/her back up against the wall. During an interview on 06/05/24, Staff 6 (Med Tech) stated the following: - "Shortly after the first incident" 15 minute checks and 1-on-1 put in place; - "There's been a few things I believe [since the first incident]  ... at least two additional [incidents];" - "I was here last night, I saw that [the incident with Residents 1 and 3 in the shower] with my own eyes;" and - "The person that was supposed to be 1-on-1 [with Resident 1] had laid [him/her] down and was doing hall room checks." During an interview on 06/06/24, Witness 1 (Hospice RN) stated "No, [Resident 1] can't consent to anything." S/he further stated Resident 1 was incapable of undressing his/herself. Resident 1's service plan, dated 03/12/24, indicated s/he required "care staff to assist [Resident 1] with all undressing and dressing needs," "demonstrates inappropriate judgment, behavior, and ability to function in social settings," and "has severe memory loss." The facility's failure to monitor Resident 1 consistent with his/her evaluated needs, by providing one-on-one supervision, placed Resident 1 at repeated risk of further harm. LCU requested a safety plan for Residents 1, 2, and 3 on 06/05/24 at approximately 8:30 pm. Safety plans for Residents 1, 2, and 3, were provided by the facility and accepted by LCU at approximately 10:25 pm. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2, Staff 3, Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President). The Department placed a condition on the facility on 06/07/24. Based on observation, interview, and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to monitor a resident consistent with his or her evaluated needs and service plan. The facility was to provide one-on-one supervision for the safety of Resident 1 and failed to do so. Findings include, but are not limited to: An incident report, dated 05/30/24, indicated Resident 1 was found in Resident 2's room undressed, and Resident 2 was in the process of undressing. It further indicated sexual abuse had been "ruled out." During an interview on 06/05/24, Staff 2 (LPN) stated Resident 1 had moved rooms. An incident report, dated 05/31/24, indicated the following: - Resident 1 had been found in Resident 2's room; - Resident 1 and Resident 2 were unclothed; - Resident 2 was attempting to penetrate Resident 1 sexually; - An assessment had been conducted on Resident 1 and there were "no signs of sexual abuse noted;" and - Resident 1 had "small yellowing bruises on [his/her] right buttock that appeared to be days old." During an interview on 06/05/24, Staff 2 (LPN) stated Resident 1 had been placed on 15-minute checks on 05/31/24 and placed under 1-on-1 supervision on 06/01/24. S/he further stated the facility RN had not been notified of the incidents on 05/30/24, 05/31/24, 06/02/24, or 06/04/24 as of approximately 6:35 pm on 06/05/24. Fifteen-minute safety check logs for Resident 1 obtained on 06/05/24 were dated 06/02/24 through 06/05/24. There was no prior documented evidence 15-minute safety checks had been implemented for Resident 1. A temporary service plan, dated 06/01/24, indicated Resident 1 "needs to be 1-on-1 with a care staff at all times to ensure [his/her] safety." Staff training documentation for Resident 1's 1-on-1 requirement indicated staff signed the document on 06/05/24. An incident report, dated 06/02/24, indicated that at approximately 5:00 am Resident 1 had been found by staff on Resident 3's bed. Resident 1 was fully clothed, while Resident 3 was partially undressed and touching his/herself sexually over Resident 1. It further indicated "no signs of sexual abuse were noted." In an interview on 06/05/24, Staff 3 (Lead Med Tech) stated the employee that was supposed to be doing the 1-on-1 had been suspended. S/he further stated the 15-minute safety check log had been started on 06/02/24 and the 1-on-1 supervision had been in place before 06/02/24. An incident report, dated 06/04/24, indicated Resident 1 had been found cornered by Resident 3, in Resident 3's shower, with his/her back up against the wall. During an interview on 06/05/24, Staff 6 (Med Tech) stated the following: - "Shortly after the first incident" 15 minute checks and 1-on-1 put in place; - "There's been a few things I believe [since the first incident]  ... at least two additional [incidents];" - "I was here last night, I saw that [the incident with Residents 1 and 3 in the shower] with my own eyes;" and - "The person that was supposed to be 1-on-1 [with Resident 1] had laid [him/her] down and was doing hall room checks." During an interview on 06/06/24, Witness 1 (Hospice RN) stated "No, [Resident 1] can't consent to anything." S/he further stated Resident 1 was incapable of undressing his/herself. Resident 1's service plan, dated 03/12/24, indicated s/he required "care staff to assist [Resident 1] with all undressing and dressing needs," "demonstrates inappropriate judgment, behavior, and ability to function in social settings," and "has severe memory loss." The facility's failure to monitor Resident 1 consistent with his/her evaluated needs, by providing one-on-one supervision, placed Resident 1 at r”

“Based on interview and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to ensure the facility RN is notified of nursing needs for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: The facility's "Intimacy/Sexual Intimacy/Sexual Assault" policy indicated "When residents express a desire to have an intimate/sexual relationship, the facility administrator and the facility RN will be notified and immediate steps taken to determine interventions related to the residents' intimacy and sexual needs ... If abuse is alleged or suspected, follow the processes described in the Abuse Policies and / or the sexual assault process above." During an interview on 06/05/24, Staff 2 (LPN) stated s/he had not notified the facility RN of multiple incidents of possible sexual assault occurring on 05/30/24, 05/31/24, and 06/02/24 involving Residents 1, 2, and 3 as of 06/05/24. During an interview on 06/07/24, Staff 10 (RN) stated s/he had not been notified of multiple incidents involving Resident 1 until 06/07/24. There was no documented evidence the facility RN had been notified of the incidents involving Resident 1 by 06/05/24. LCU requested a safety plan for Resident 1 on 06/05/24 at approximately 8:30 pm. A safety plan for Resident 1 was provided by the facility and accepted by LCU at approximately 10:25 pm. It was determined the facility failed to ensure the facility RN was notified of nursing needs for a resident. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2 (LPN), Staff 3 (Lead Med Tech), Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President). The Department placed a condition on the facility on 06/07/24. Based on interview and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to ensure the facility RN is notified of nursing needs for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: The facility's "Intimacy/Sexual Intimacy/Sexual Assault" policy indicated "When residents express a desire to have an intimate/sexual relationship, the facility administrator and the facility RN will be notified and immediate steps taken to determine interventions related to the residents' intimacy and sexual needs ... If abuse is alleged or suspected, follow the processes described in the Abuse Policies and / or the sexual assault process above." During an interview on 06/05/24, Staff 2 (LPN) stated s/he had not notified the facility RN of multiple incidents of possible sexual assault occurring on 05/30/24, 05/31/24, and 06/02/24 involving Residents 1, 2, and 3 as of 06/05/24. During an interview on 06/07/24, Staff 10 (RN) stated s/he had not been notified of multiple incidents involving Resident 1 until 06/07/24. There was no documented evidence the facility RN had been notified of the incidents involving Resident 1 by 06/05/24. LCU requested a safety plan for Resident 1 on 06/05/24 at approximately 8:30 pm. A safety plan for Resident 1 was provided by the facility and accepted by LCU at approximately 10:25 pm. It was determined the facility failed to ensure the facility RN was notified of nursing needs for a resident. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2 (LPN), Staff 3 (Lead Med Tech), Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President). The Department placed a condition on the facility on 06/07/24.”

“Based on observation, interview, and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to provide effective administrative oversight over the operation of the Memory Care Community (MCC). 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 includes the supervision and overall conduct of the staff. During the LCU investigation, conducted 06/05/24 through 06/07/24, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the severity of citations in the following areas: OAR 411-054-0025(7)(f) Facility Adminstration; OAR 411-054-0040(2)(a) Change of Condition and Monitoring; and OAR 411-054-0045(1)(d) Resident Health Services. LCU requested a safety plan for Residents 1, 2, and 3 on 06/05/24 at approximately 8:30 pm. Safety plans for Residents 1, 2, and 3, were provided by the facility and accepted by LCU at approximately 10:25 pm. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2 (LPN), Staff 3 (Lead Med Tech), Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President). The Department placed a condition on the facility on 06/07/24. Based on observation, interview, and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to provide effective administrative oversight over the operation of the Memory Care Community (MCC). 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 includes the supervision and overall conduct of the staff. During the LCU investigation, conducted 06/05/24 through 06/07/24, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the severity of citations in the following areas: OAR 411-054-0025(7)(f) Facility Adminstration; OAR 411-054-0040(2)(a) Change of Condition and Monitoring; and OAR 411-054-0045(1)(d) Resident Health Services. LCU requested a safety plan for Residents 1, 2, and 3 on 06/05/24 at approximately 8:30 pm. Safety plans for Residents 1, 2, and 3, were provided by the facility and accepted by LCU at approximately 10:25 pm. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2 (LPN), Staff 3 (Lead Med Tech), Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President). The Department placed a condition on the facility on 06/07/24.”

“Based on observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240. Based on observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240. See C 240 See C 240 Based on observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 240. Based on observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 240. There are no detail notes for this visit.”

“The findings of the kitchen inspection, conducted 04/03/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the kitchen inspection, conducted 04/03/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the first revisit to the kitchen inspection of 04/03/24, conducted 07/09/24 through 07/10/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the first revisit to the kitchen inspection of 04/03/24, conducted 07/09/24 through 07/10/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the second revisit to the kitchen inspection of 04/03/24, conducted 09/05/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the second revisit to the kitchen inspection of 04/03/24, conducted 09/05/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the third re-visit to the kitchen inspection of 04/03/24, conducted on 10/30/24, 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 third re-visit to the kitchen inspection of 04/03/24, conducted on 10/30/24, 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 04/03/24 at 11:15 am, the facility kitchen was observed to need cleaning in the following areas: a. Food spills, splatters, debris, dirt, dust, grease and/or black/brown matter was observed on or underneath the following: * Bottom shelf of the counter top refrigerator next to coffee maker; - food debris/spills on bottom shelf, freezer with significant ice buildup; * Vents below the doors of refrigerators #2 and #4; * Bottom shelves and vents below the doors of Freezers #1 and #2; * The oven doors and sides of stove/grill; * The hood vents above the stove/grill; * The lower shelves of counters and preparation areas throughout the kitchen including: - counters next to stove/grill; - holding mixer attachments; - cupboards with doors in front of steam table holding clean dishes; - under steam table; * Walls and ceiling throughout the kitchen including: - in the dishwashing area below the rack shelf; - behind the spray hose and dishwasher; - wall area above and below counter holding blenders next to the stove/grill; - wall surrounding handwashing sink behind the stove wall & underneath sink areas; - wall area behind the three sink area; - above the window air conditioner; - wall next to the exterior door; - ceiling vents above steam table; and - pan storage area; * Window air conditioner, which was in operation (blowing air) creating potential for cross contamination; * Food slicer and holding shelf beneath the slicer; and * Flooring throughout the kitchen, including: dry storage area; dishwashing area; corners and underneath counters and storage shelves. b. Other findings included: *Freezer #1 - not all food items were frozen solid, temperature at 30 degrees F; * Refrigerators #2, #4 and freezer #1 contained containers and repackaged food items which were unlabeled/undated (imitation crab; pears; cut fruit; lunch meat; cheese slices); * Cardboard boxes of disposable containers and foil sheets were stored on the floor in dry storage area; and *One uncovered garbage can. The findings were discussed with Staff 1 (Med Tech serving as kitchen PIC), Staff 2 (Executive Director) and Staff 3 (ALF Administrator) on 04/03/24. 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 04/03/24 at 11:15 am, the facility kitchen was observed to need cleaning in the following areas: a. Food spills, splatters, debris, dirt, dust, grease and/or black/brown matter was observed on or underneath the following: * Bottom shelf of the counter top refrigerator next to coffee maker; - food debris/spills on bottom shelf, freezer with significant ice buildup; * Vents below the doors of refrigerators #2 and #4; * Bottom shelves and vents below the doors of Freezers #1 and #2; * The oven doors and sides of stove/grill; * The hood vents above the stove/grill; * The lower shelves of counters and preparation areas throughout the kitchen including: - counters next to stove/grill; - holding mixer attachments; - cupboards with doors in front of steam table holding clean dishes; - under steam table; * Walls and ceiling throughout the kitchen including: - in the dishwashing area below the rack shelf; - behind the spray hose and dishwasher; - wall area above and below counter holding blenders next to the stove/grill; - wall surrounding handwashing sink behind the stove wall & underneath sink areas; - wall area behind the three sink area; - above the window air conditioner; - wall next to the exterior door; - ceiling vents above steam table; and - pan storage area; * Window air conditioner, which was in operation (blowing air) creating potential for cross contamination; * Food slicer and holding shelf beneath the slicer; and * Flooring throughout the kitchen, including: dry storage area; dishwashing area; corners and underneath counters and storage shelves. b. Other findings included: *Freezer #1 - not all food items were frozen solid, temperature at 30 degrees F; * Refrigerators #2, #4 and freezer #1 contained containers and repackaged food items which were unlabeled/undated (imitation crab; pears; cut fruit; lunch meat; cheese slices); * Cardboard boxes of disposable containers and foil sheets were stored on the floor in dry storage area; and *One uncovered garbage can. The findings were discussed with Staff 1 (Med Tech serving as kitchen PIC), Staff 2 (Executive Director) and Staff 3 (ALF Administrator) on 04/03/24. The findings were acknowledged. A deep cleaning of all kitchen areas identified has been completed as of 4/17/2024 by all kitchen staff. A daily cleaning log for all kitchen areas identified has been re-established and is placed in a binder for staff to initial as they are completed.  The Food Service Director is responsible for ensuring this is completed daily and in her absence, the responsibility is that of the Lead cook. The Executive Director is responsible for auditing that this is completed weekly. In the absence of the ED, the Administrator of the AL will be responsible. An audit of the kitchen using the CBC audit form will be completed weekly by the Food Service Director.  The Executive Director is responsible for auditing that this is completed weekly. In the absence of the ED, the Administrator of the AL will be responsible. The Maintenance Director has removed, cleaned and repainted the vents and is responsible for observing these monthly to ensure they are not in need of repair. The Executive Director is responsible for auditing that this is completed. In the absence of the ED, the Administrator of the AL will be responsible. Items were removed from Freezer, temped, and prepared in proper time to ensure no food-borne illnesses occurred on 04/03/2024. Freezer was repaired on 4/5/2024 and a temperature log is located in the kitchen to ensure the temperature of all refrigerators and freezers are at temperature and keeping the food cold.  An internal thermometer was placed in all refrigerators, and this will be used for documentation rather than the exterior digital thermometers to ensure that the proper temp is kept and documented. This in-service with all kitchen staff will be completed by 5/1/2024 All kitchen staff will be retrained on labeling/dating opened food, cleaning lists, food and dry storage not being placed on the ground, lids on garbage cans always.  Cleaning lists will be reviewed, and all staff agree that they understand the cleaning expected of them and the proper documentation of cleaning completed and temperatures for both food, dishwasher, and refrigerator/freezers.  This in-service with all kitchen staff will be completed by 5/1/2024. Crandall Dietitians will be completing quarterly audits of facility kitchen and serving in the dining room as well as special diets. These will be reviewed with Food Service Director and Executive Director. A deep cleaning of all kitchen areas identified has been completed as of 4/17/2024 by all kitchen staff. A daily cleaning log for all kitchen areas identified has been re-established and is placed in a binder for staff to initial as they are completed.  The Food Service Director is responsible for ensuring this is completed daily and in her absence, the responsibility is that of the Lead cook. The Executive Director is responsible for auditing that this is completed weekly. In the absence of the ED, the Administrator of the AL will be responsible. An audit of the kitchen using the CBC audit form will be completed weekly by the Food Service Director.  The Executive Director is responsible for auditing that this is”

“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. Please see our plan of corrections at C240 Please see our plan of corrections at C240 Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 240. Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 240. See C 240 See C 240 Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 240. Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 240. There are no detail notes for this visit.”

“The findings of the re-licensure survey conducted 08/14/23 through 08/17/23 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 The findings of the re-licensure survey conducted 08/14/23 through 08/17/23 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 The findings of the first revisit to the re-licensure survey of 08/17/23, conducted 01/02/24  through 01/05/24, 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 A situation was identified during the survey where failure of the facility to comply with the Department's rules was likely to cause residents serious harm. An immediate plan of correction was requested in the following area: OAR 411-054-0025 (4) Reasonable Precautions The facility put an immediate plan of correction in place during the survey and the situation that could cause residents serious harm was abated. The findings of the first revisit to the re-licensure survey of 08/17/23, conducted 01/02/24  through 01/05/24, 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 A situation was identified during the survey where failure of the facility to comply with the Department's rules was likely to cause residents serious harm. An immediate plan of correction was requested in the following area: OAR 411-054-0025 (4) Reasonable Precautions The facility put an immediate plan of correction in place during the survey and the situation that could cause residents serious harm was abated. The findings of the 2nd revisit to the re-licensure survey of 08/17/23, conducted 04/03/24 through 04/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 2nd revisit to the re-licensure survey of 08/17/23, conducted 04/03/24 through 04/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 ”

“Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety or welfare of residents for 3 of 3 sampled residents (#s 8, 9, and 10) who received inaccurate fluid consistencies.  Residents received inaccurate fluid consistencies, placing them at risk for aspiration, choking and/or death. Findings include, but are not limited to: During the survey on 01/02/24, three sampled residents were identified as requiring modified texture meals and/or modified liquid consistencies. Resident 8, 9, and 10's clinical records were reviewed. Resident 8 had a physician order dated 12/14/23 for nectar thick consistency liquids.  Resident 10 had a signed physician order, dated 11/25/22, indicating s/he required pureed textures and nectar thick liquids.  Resident 9 had a physician order dated 10/09/23 for regular/thin diet and fluid consistency. Resident 8, 9, and 10's service plans revealed the following: *Resident 8's current service plan dated 11/21/23 noted the resident had a history of swallowing difficulties and required a pureed texture diet with pudding thick liquids. *Resident 9's current service plan dated 12/21/23 noted the resident was on a mechanical soft texture diet and no specifications for fluid consistency. *Resident 10's clinical record and current service plan dated 11/15/23 noted the resident was on a puree diet texture with nectar thick liquids. During meal observations of Resident 8, 9, and 10 and interviews with staff on 01/02/24 between 11:47 am and 1:15 pm, the following was noted: * Resident 8 required assistance to eat and drink during the noon meal; * Resident 8 had non-thickened water served at his/her place setting; * Staff 19 and 24 (CGs) were not able to state what fluid consistency the resident required; * Staff 24 removed the non-thickened water from the resident and served the resident nectar thick juice; * Staff 24 stated the resident needed "really" thick liquids and added approximately 1/4 cup of thickening agent to the juice; * Staff 19 (CG) spoon fed the juice with "pudding like consistency" to the resident; * Resident 10 required assistance to eat and drink during the noon meal; * Resident 10 had non-thickened water served at her/his place setting; * Staff 19 (CG) was not able to state what fluid consistency Resident 10 required; * Staff 24 (CG) removed the non-thickened water and stated Resident 10 was on a "thick liquid"; * Prior to lunch being served, Resident 9 would stand up from the table and walk around the dining room and attempted to take other residents' silverware and/or drinks. Staff observed to intervene and give resident non-thickened glasses of water while walking around and/or when seated at the table. Resident 9 drank three glasses of non-thickened water prior to the noon meal. * Resident 9 required assistance to eat during the noon meal; * Staff 19 (CG) stirred a glass of water and gave to Resident 9 while s/he was eating. Staff 19 confirmed she had added powdered thickener to Resident 9's water but could not state what fluid consistency the resident required; * Staff 24 (CG) stated Resident 9 was nectar thick; and * Resident 9 was observed to drink the water provided by Staff 19. Resident 8, 9 and 10 either received thickened liquid without an order or received the incorrect fluid consistency.  Staff 19 and 24 were unaware of what consistency the resident's required and were not clear on how much thickening agent to add to liquids. The facility failed to ensure residents who required modified fluid consistencies were served the appropriate fluid as evaluated or prescribed. This placed the residents at risk for choking, aspiration, and/or death. On 01/02/23 Staff 27 (Lead Cook) stated that the facility used pre-thickened water but the facility currently did not have any. Staff 3 (Lead Med Tech) stated the facility started using the powdered thickening agent "last week" when the pre-thickened water was not delivered by the food company. She acknowledged the staff should have received some training in using the powder to thicken liquids. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 (ED) on 01/02/24 at 1:25 pm. An immediate plan of correction was requested by the survey team on 01/02/24 at 2:30 pm. The IJ plan of correction was presented to the surveyors and approved on 01/02/24 at 3:35 pm. The situation was abated. Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety or welfare of residents for 3 of 3 sampled residents (#s 8, 9, and 10) who received inaccurate fluid consistencies.  Residents received inaccurate fluid consistencies, placing them at risk for aspiration, choking and/or death. Findings include, but are not limited to: During the survey on 01/02/24, three sampled residents were identified as requiring modified texture meals and/or modified liquid consistencies. Resident 8, 9, and 10's clinical records were reviewed. Resident 8 had a physician order dated 12/14/23 for nectar thick consistency liquids.  Resident 10 had a signed physician order, dated 11/25/22, indicating s/he required pureed textures and nectar thick liquids.  Resident 9 had a physician order dated 10/09/23 for regular/thin diet and fluid consistency. Resident 8, 9, and 10's service plans revealed the following: *Resident 8's current service plan dated 11/21/23 noted the resident had a history of swallowing difficulties and required a pureed texture diet with pudding thick liquids. *Resident 9's current service plan dated 12/21/23 noted the resident was on a mechanical soft texture diet and no specifications for fluid consistency. *Resident 10's clinical record and current service plan dated 11/15/23 noted the resident was on a puree diet texture with nectar thick liquids. During meal observations of Resident 8, 9, and 10 and interviews with staff on 01/02/24 between 11:47 am and 1:15 pm, the following was noted: * Resident 8 required assistance to eat and drink during the noon meal; * Resident 8 had non-thickened water served at his/her place setting; * Staff 19 and 24 (CGs) were not able to state what fluid consistency the resident required; * Staff 24 removed the non-thickened water from the resident and served the resident nectar thick juice; * Staff 24 stated the resident needed "really" thick liquids and added approximately 1/4 cup of thickening agent to the juice; * Staff 19 (CG) spoon fed the juice with "pudding like consistency" to the resident; * Resident 10 required assistance to eat and drink during the noon meal; * Resident 10 had non-thickened water served at her/his place setting; * Staff 19 (CG) was not able to state what fluid consistency Resident 10 required; * Staff 24 (CG) removed the non-thickened water and stated Resident 10 was on a "thick liquid"; * Prior to lunch being served, Resident 9 would stand up from the table and walk around the dining room and attempted to take other residents' silverware and/or drinks. Staff observed to intervene and give resident non-thickened glasses of water while walking around and/or when seated at the table. Resident 9 drank three glasses of non-thickened water prior to the noon meal. * Resident 9 required assistance to eat during the noon meal; * Staff 19 (CG) stirred a glass of water and gave to Resident 9 while s/he was eating. Staff 19 confirmed she had added powdered thickener to Resident 9's water but could not state what fluid consistency the resident required; * Staff 24 (CG) stated Resident 9 was nectar thick; and * Resident 9 was observed to drink the water provided by Staff 19. Resident 8, 9 and 10 either received thickened liquid without a”

“Based on observation and interview, it was determined the facility failed to ensure resident's right to privacy and dignity was maintained related to providing ADL care for 1 of 3 sampled residents (# 8) whose ADL care was observed.  Findings include, but are not limited to: Resident 8 was admitted to the facility in 08/2023 with diagnoses including vascular dementia and shared an apartment with a non-sampled resident. Observation and interviews with staff during the survey identified Resident 8 as dependent on staff for ADL care.  Resident 8 required two person assist with ADL care including incontinent care which was provided while the resident was in bed. During an ADL observation on 01/03/24 at 1:28 pm in the resident apartment, Staff 24 (CG) and Staff 25 (Life Enrichment Coordinator) provided the following: * Two person transfer lifting the resident from a wheelchair into bed; * Cueing and directions regarding incontinency care was provided; * The resident's pants were removed and then the soiled incontinent brief was removed; * Perineal care was provided using multiple incontinency wipes; * Clean incontinent brief was put on the resident; and * Resident 8 was repositioned in bed and a blanket was used to cover his/her lower body. The ADL care was provided in the resident apartment in the presence of the roommate and a lack of a privacy curtain. The need to ensure privacy and maintain resident dignity while providing incontinent care for Resident 8 was discussed with Staff 24 and Staff 25.  Staff acknowledged the lack of privacy and stated they would utilize a privacy curtain. A privacy curtain was observed in Resident 8's room on 01/04/24 at 10:00 am. The lack of privacy and dignity afforded to Resident 8 was reviewed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24 at 11:40 am.  Staff acknowledged the finding. Based on observation and interview, it was determined the facility failed to ensure resident's right to privacy and dignity was maintained related to providing ADL care for 1 of 3 sampled residents (# 8) whose ADL care was observed.  Findings include, but are not limited to: Resident 8 was admitted to the facility in 08/2023 with diagnoses including vascular dementia and shared an apartment with a non-sampled resident. Observation and interviews with staff during the survey identified Resident 8 as dependent on staff for ADL care.  Resident 8 required two person assist with ADL care including incontinent care which was provided while the resident was in bed. During an ADL observation on 01/03/24 at 1:28 pm in the resident apartment, Staff 24 (CG) and Staff 25 (Life Enrichment Coordinator) provided the following: * Two person transfer lifting the resident from a wheelchair into bed; * Cueing and directions regarding incontinency care was provided; * The resident's pants were removed and then the soiled incontinent brief was removed; * Perineal care was provided using multiple incontinency wipes; * Clean incontinent brief was put on the resident; and * Resident 8 was repositioned in bed and a blanket was used to cover his/her lower body. The ADL care was provided in the resident apartment in the presence of the roommate and a lack of a privacy curtain. The need to ensure privacy and maintain resident dignity while providing incontinent care for Resident 8 was discussed with Staff 24 and Staff 25.  Staff acknowledged the lack of privacy and stated they would utilize a privacy curtain. A privacy curtain was observed in Resident 8's room on 01/04/24 at 10:00 am. The lack of privacy and dignity afforded to Resident 8 was reviewed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24 at 11:40 am.  Staff acknowledged the finding. A privacy curtain was provided for the resident receiving care to preserve her dignity and privacy. Retraining was provided for all staff regarding resident privacy and dignity. Staff were asked to provide privacy curtain for any resident they are providing care for if they are unable to provide care behind closed door or without the roommate leaving the room to protect privacy. RSC, Lead Med Tech and ED will audit this on each shift at least 3 times weekly for 1 month and then weekly thereafter to ensure resident rights are being observed and dignity and privacy are being provided. ED will be responsible for ensuring this is completed/monitored. A privacy curtain was provided for the resident receiving care to preserve her dignity and privacy. Retraining was provided for all staff regarding resident privacy and dignity. Staff were asked to provide privacy curtain for any resident they are providing care for if they are unable to provide care behind closed door or without the roommate leaving the room to protect privacy. RSC, Lead Med Tech and ED will audit this on each shift at least 3 times weekly for 1 month and then weekly thereafter to ensure resident rights are being observed and dignity and privacy are being provided. ED will be responsible for ensuring this is completed/monitored. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 2 sampled residents (#6) who were receiving PRN psychotropic medications. Findings include, but are not limited to: Resident 6 was admitted to the facility in 04/2023 with diagnoses including vascular dementia and major depressive disorder. Review of Resident 6's MAR, dated 07/01/23 through 08/14/23, and physician orders revealed the following: * Resident 6 was prescribed lorazepam 1 mg every four hours as needed for nausea/agitation/anxiety, and it was documented as administered to the resident on eight occasions between 07/22/23 and 08/11/23; and * Haldol 4 mg every six hours as needed for agitation, and it was documented as administered to the resident on seven occasions between 07/09/23 and 07/31/23. The facility lacked documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the medications and the MAR lacked information on non-pharmacological interventions for staff to attempt. In an interview on 08/15/23, Staff 3 (Lead MT) confirmed the MAR and electronic system did not have non-pharmacological interventions listed for staff to attempt prior to administering the PRN medications. On 08/16/23, the need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (RN/Resident Services Coordinator). They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 2 sampled residents (#6) who were receiving PRN psychotropic medications. Findings include, but are not limited to: Resident 6 was admitted to the facility in 04/2023 with diagnoses including vascular dementia and major depressive disorder. Review of Resident 6's MAR, dated 07/01/23 through 08/14/23, and physician orders revealed the following: * Resident 6 was prescribed lorazepam 1 mg every four hours as needed for nausea/agitation/anxiety, and it was documented as administered to the resident on eight occasions between 07/22/23 and 08/11/23; and * Haldol 4 mg every six hours as needed for agitation, and it was documented as administered to the resident on seven occasions between 07/09/23 and 07/31/23. The facility lacked documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the medications and the MAR lacked information on non-pharmacological interventions for staff to attempt. In an interview on 08/15/23, Staff 3 (Lead MT) confirmed the MAR and electronic system did not have non-pharmacological interventions listed for staff to attempt prior to administering the PRN medications. On 08/16/23, the need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (RN/Resident Services Coordinator). They acknowledged the findings. All residents non-pharmacological interventions were reviewed by Resident Services Coordinator (RN). These were implemented in PCC (service plans) in addition to being listed on the MAR in the proper place for documentation. These will be audited weekly by RSC (RN) and reviewed with Executive Director and Lead Med Tech weekly to ensure Alternative Measures are being used appropriately and their effectiveness. Documentation of these audits will be kept in Executive Director's office and reviewed monthly by Executive Director to ensure they are being completed. All residents non-pharmacological interventions were reviewed by Resident Services Coordinator (RN). These were implemented in PCC (service plans) in addition to being listed on the MAR in the proper place for documentation. These will be audited weekly by RSC (RN) and reviewed with Executive Director and Lead Med Tech weekly to ensure Alternative Measures are being used appropriately and their effectiveness. Documentation of these audits will be kept in Executive Director's office and reviewed monthly by Executive Director to ensure they are being completed. There are no detail notes for this visit.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs and provided clear instruction to staff for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 06/2020 with diagnoses including dementia. Interviews with care staff and observations of Resident 1 during the survey revealed s/he was incontinent, dependent on staff for ADL care, and did not use a call light to summon assistance. Resident 1's current service plan, dated 06/09/23, failed to provide specific instruction to staff in the following areas: * Toileting; * Evacuation; * Life Enrichment; * Bathing; * Dressing/Undressing; and * Personal hygiene/oral care. The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. The findings were acknowledged. 2. Resident 4 was admitted to the facility in 08/2018 with diagnoses including dementia. Interviews with care staff and observations of Resident 4 during the survey revealed s/he was incontinent and dependent on staff for ADL care. Resident 4's current service plan, dated 06/28/23, lacked specific instruction to staff in the following areas: * Toileting; * Evacuation; * Life Enrichment; * Bathing; * Dressing/Undressing; and * Personal hygiene/oral care. The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. The findings were acknowledged. Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs and provided clear instruction to staff for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:”

“Based on interview, and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4's current service plans were reviewed during the survey. On 08/16/23 at 1:50 pm, Staff 1 (ED) confirmed the facility lacked documented evidence of a Service Planning Team to develop the individual service plan. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 on 08/17/23 at 12:45 pm. She 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 that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4's current service plans were reviewed during the survey. On 08/16/23 at 1:50 pm, Staff 1 (ED) confirmed the facility lacked documented evidence of a Service Planning Team to develop the individual service plan. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 on 08/17/23 at 12:45 pm. She acknowledged the findings. Service Plan Acknowledgement forms have been re-implemented.  These will be signed by all members of the service planning team and management will document who is involved and any distribution of service plan to family, POA or guardian if not available to sign.  This will be kept in a binder located in the Executive Director's office. This will be audited weekly by Resident Service Coordinator and Executive Director and as needed to ensure that Service Plan team is documented accurately and timely. Service Plan Acknowledgement forms have been re-implemented.  These will be signed by all members of the service planning team and management will document who is involved and any distribution of service plan to family, POA or guardian if not available to sign.  This will be kept in a binder located in the Executive Director's office. This will be audited weekly by Resident Service Coordinator and Executive Director and as needed to ensure that Service Plan team is documented accurately and timely. There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to: During the survey, multiple meal observations were made of staff providing meal assistance to residents. Staff were observed wearing gloves, touching wheelchairs, cellular phones, their hair, faces and then continued to provide meal assistance without having changed their gloves. The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene, while providing meal assistance to residents, was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. The findings were acknowledged. Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to: During the survey, multiple meal observations were made of staff providing meal assistance to residents. Staff were observed wearing gloves, touching wheelchairs, cellular phones, their hair, faces and then continued to provide meal assistance without having changed their gloves. The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene, while providing meal assistance to residents, was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. The findings were acknowledged. All-staff retraining on infection control and hand-washing will be held on 9/1/2023 by Executive Director and Resident Services Coordinator.  On-going training in Relias Learning will be assigned quarterly. The sink was returned to the dining room on 8/21/2023 which assists with handwashing during serve-out. Hand-washing/infection control will be observed minimum 5 days a week for 4 weeks and 2 times a week ongoing. This will be completed by Executive Director, Resident Services Coordinator, or Lead Med Tech for at least one meal.  This will be documented and kept in the Executive Director's office. All-staff retraining on infection control and hand-washing will be held on 9/1/2023 by Executive Director and Resident Services Coordinator.  On-going training in Relias Learning will be assigned quarterly. The sink was returned to the dining room on 8/21/2023 which assists with handwashing during serve-out. Hand-washing/infection control will be observed minimum 5 days a week for 4 weeks and 2 times a week ongoing. This will be completed by Executive Director, Resident Services Coordinator, or Lead Med Tech for at least one meal.  This will be documented and kept in the Executive Director's office.”

“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 2 of 2 sampled residents (#s 3 and 4) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to: 1. Resident 3 was admitted in 07/2019 and had diagnoses which included dementia. a. Resident 3 had an order for hydrocodone-acetaminophen (narcotic analgesic) 5-325 mg, one tablet every four hours PRN for pain. Resident 1's Controlled Substance Disposition Logs and MARs, reviewed from 07/01/23 to 07/31/23 , revealed five occasions when staff signed on the drug disposition log that the hydrocodone was taken out of the locked storage to administer. However, the MAR lacked documentation that the resident received the medication. b. Resident 3 had an order for morphine 7.5 mg tablet (narcotic analgesic), every eight hours PRN for pain. Resident 1's Controlled Substance Disposition Logs and MARs, reviewed from 07/01/23 to 07/31/23 , revealed three occasions when staff signed on the drug disposition log that the morphine was taken out of the locked storage to administer. However, the MAR lacked documentation that the resident received the medication. Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Staff 2 (RN/Resident Services Coordinator) on 08/17/23. They reviewed the documentation and acknowledged the discrepancies. 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 2 of 2 sampled residents (#s 3 and 4) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 1 of 5 sampled residents (# 7) whose orders were reviewed. Findings include, but are not limited to: Resident 7 was admitted to the facility in 02/2022 with diagnoses including Type II diabetes mellitus. Resident 7's MAR, dated 07/01/23 through 08/15/23 and prescriber orders were reviewed on 08/15/23. Resident had a physician's order for Novolog (insulin) to be administered before meals according to a sliding scale dosage. The facility did not have a signed physician's order for the resident's current sliding scale dosage. Staff 2 (RN/Resident Services Coordinator) was interviewed on 08/16/23 and was not able to locate the current signed order for the sliding scale doses. Staff 2 stated she had contacted the resident's PCP and was awaiting the order. No additional information was provided. The need to ensure the facility had signed physician's orders for all medications administered by staff was discussed with Staff 1 (ED) and Staff 2 on 08/17/23. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 1 of 5 sampled residents (# 7) whose orders were reviewed. Findings include, but are not limited to: Resident 7 was admitted to the facility in 02/2022 with diagnoses including Type II diabetes mellitus. Resident 7's MAR, dated 07/01/23 through 08/15/23 and prescriber orders were reviewed on 08/15/23. Resident had a physician's order for Novolog (insulin) to be administered before meals according to a sliding scale dosage. The facility did not have a signed physician's order for the resident's current sliding scale dosage. Staff 2 (RN/Resident Services Coordinator) was interviewed on 08/16/23 and was not able to locate the current signed order for the sliding scale doses. Staff 2 stated she had contacted the resident's PCP and was awaiting the order. No additional information was provided. The need to ensure the facility had signed physician's orders for all medications administered by staff was discussed with Staff 1 (ED) and Staff 2 on 08/17/23. They acknowledged the findings. Current and correct order for resident's insulin was received on 8/18/23.  Additional training was completed with each med tech regarding correct orders and notifying RSC or Lead Med Tech when orders are not matching, not complete, or not correct. Lead Med Tech and Resident Services Coordinator will review and approve orders prior to administration. If order is incorrect, MD will be contacted and med will not be administered until corrected order is in place. This will be documented in binder in ED office and findings will be reviewed minimum of once weekly with Executive Director, Resident Service Coordinator and Lead Med Tech. Executive Director will be responsible for ensuring that audits are completed. Current and correct order for resident's insulin was received on 8/18/23.  Additional training was completed with each med tech regarding correct orders and notifying RSC or Lead Med Tech when orders are not matching, not complete, or not correct. Lead Med Tech and Resident Services Coordinator will review and approve orders prior to administration. If order is incorrect, MD will be contacted and med will not be administered until corrected order is in place. This will be documented in binder in ED office and findings will be reviewed minimum of once weekly with Executive Director, Resident Service Coordinator and Lead Med Tech. Executive Director will be responsible for ensuring that audits are completed. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters and instructions for PRN medications for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5, and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1, 2, 3, 4, and 5's MARs between 07/01/23 through 08/15/23 were reviewed and the following was noted: a. Residents 3's MARs dated 08/01/23 through 08/14/23 revealed the following: Multiple incidents of medications including Eliquis (blood thinner), Gentamicin (antibiotic), and Hydroxurea (chemotherapy) with scheduled administration times left blank, failing to document administration of the medications. b. Residents 2's MARs, reviewed from 08/01/23 through 08/14/23 revealed the following: Multiple incidents of medications including buproprion (antidepressant), ezetimible (cholesterol lowering), linsinopril (blood pressure), and Insulin (blood sugar  metabolism) with scheduled administration times left blank, failing to document administration of the medications. Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters and instructions for PRN medications for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5, and 6) whose MARs were reviewed. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure an assistive device with restraining qualities was assessed by an RN, PT, or OT prior to use, and instruction provided to caregivers on precautions and correct use of the device for 2 of 2 sampled residents (#s 5 and 6) who were reviewed for devices with restraining qualities. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 11/2022 with diagnoses including Alzheimer's disease and anxiety disorder. During the survey, Resident 5 was observed while lying in bed. The bed was equipped with a half-side rail in the up position on one side of the bed. In the resident's room, a "lap buddy" type cushion was observed sitting on the wheelchair. Staff 3 (Lead MT) confirmed the "lap buddy" was obtained by the facility and used by Resident 5 when s/he was up in the wheelchair. Resident 5's service plan, last updated 03/13/23, stated "uses lap buddy to help prevent falls". The service plan did not include any information on use of the side rail. Upon request, the facility provided an "assessment of supportive devices with restraining characteristics" completed by an RN on 03/10/23, however, the assessment stated it was a review of a "lap belt". The assessment described a device used for the resident to "hold self up in the chair" and "releas[ing] the belt".  During an interview on 08/15/23, Staff 2 (RN/Resident Services Coordinator) stated the document did not appear to be accurate for a "lap buddy" type device. Staff 2 confirmed the current service plan did not include instructions for caregivers on the correct use and precautions related to use of the devices. There was no assessment available for the side rail. The need to ensure an assessment and required documentation for devices with potentially restraining qualities was completed was discussed with Staff 1 (ED) and Staff 2 on 08/16/23. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 04/2023 with diagnoses including vascular dementia. Resident 6 was observed to have a "lap buddy" type cushion. Staff 3 (Lead MT) confirmed the "lap buddy" was obtained by the facility following a recommendation by PT services and used by Resident 6 when s/he was up in the wheelchair. Resident 6's service plan, last updated 07/17/23, did not include any information on use of the lap buddy. Upon request, the facility provided an "assessment of supportive devices with restraining characteristics" completed by an RN on 05/30/23, however, the assessment stated it was a review of a "lap belt". The assessment described a device used for the resident to "hold [him/her] in the chair" and "remove the belt on [his/her] own".  During an interview on 08/15/23, Staff 2 (RN/Resident Services Coordinator) confirmed the document did not appear to be accurate for a "lap buddy" type device. Staff 2 confirmed the current service plan did not include instructions for caregivers on the correct use and precautions related to use of the device. The need to ensure an assessment and required documentation for devices with potentially restraining qualities was completed was discussed with Staff 1 (ED) and Staff 2 on 08/16/23. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure an assistive device with restraining qualities was assessed by an RN, PT, or OT prior to use, and instruction provided to caregivers on precautions and correct use of the device for 2 of 2 sampled residents (#s 5 and 6) who were reviewed for devices with restraining qualities. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to use an acuity-based staffing tool (ABST) that showed all residents with the 22 required care elements with staff time to complete them. Findings include, but are not limited to: ABST record system was reviewed with Staff 1 (ED) on 08/17/23 at 10:00 am. Staff 1 stated the facility was using "Point Click Care" to record the 22 required care elements and staff time to complete them. A record review of the ABST information provided by Staff 1 revealed the following: * ABST did not address all the required activities of daily living (ADLs) for each resident; and * ABST did not include the amount of staff time needed to provide care for the resident sample picked for the survey. In an interview on 08/17/23 at 1:30 pm, the need for the ABST tool to show all residents with the 22 required care elements with staff time to complete them, ensuring ABST provided data so the facility could develop a 24-hour schedule and an individualized task list was discussed with Staff 1. She acknowledged the findings. Based on interview and record review, it was determined the facility failed to use an acuity-based staffing tool (ABST) that showed all residents with the 22 required care elements with staff time to complete them. Findings include, but are not limited to: ABST record system was reviewed with Staff 1 (ED) on 08/17/23 at 10:00 am. Staff 1 stated the facility was using "Point Click Care" to record the 22 required care elements and staff time to complete them. A record review of the ABST information provided by Staff 1 revealed the following: * ABST did not address all the required activities of daily living (ADLs) for each resident; and * ABST did not include the amount of staff time needed to provide care for the resident sample picked for the survey. In an interview on 08/17/23 at 1:30 pm, the need for the ABST tool to show all residents with the 22 required care elements with staff time to complete them, ensuring ABST provided data so the facility could develop a 24-hour schedule and an individualized task list was discussed with Staff 1. She acknowledged the findings. ABST is updated and accurate on the ODHS provided tool to ensure all 22 required care elements are met. This will be updated twice weekly by the Resident Service Coordinator or Executive Director during service plan meetings and as needed. Executive Director to audit weekly to ensure that the corrections are completed and monitored ongoing. ABST is updated and accurate on the ODHS provided tool to ensure all 22 required care elements are met. This will be updated twice weekly by the Resident Service Coordinator or Executive Director during service plan meetings and as needed. Executive Director to audit weekly to ensure that the corrections are completed and monitored ongoing. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternate months from fire drills in accordance with the Oregon Fire Code (OFC), document all required components of the drills and failed to identify residents who were unwilling or failed to participate in drills. Findings include, but are not limited to: The previous six months of fire drill and fire and life safety training records were reviewed on 08/16/23 with Staff 1 (ED). The following were identified: a. Fire and life safety training for staff: * The facility lacked documented evidence of fire and life safety training for staff on alternate months. b. Fire Drills: * There was no documentation of problems encountered, comments relating to residents who resisted or failed to participate in the drills; * There was was no documented evidence the facility had identified residents who were unwilling or failed to participate in fire drills and made immediate changes to ensure evacuation standards were being met. The need to ensure fire drills were completed and all required components were documented and fire and life safety training for staff was conducted, per the rules, was reviewed with Staff 1 on 08/16/23 and 08/17/23. She acknowledged the findings. Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternate months from fire drills in accordance with the Oregon Fire Code (OFC), document all required components of the drills and failed to identify residents who were unwilling or failed to participate in drills. Findings include, but are not limited to: The previous six months of fire drill and fire and life safety training records were reviewed on 08/16/23 with Staff 1 (ED). The following were identified: a. Fire and life safety training for staff: * The facility lacked documented evidence of fire and life safety training for staff on alternate months. b. Fire Drills: * There was no documentation of problems encountered, comments relating to residents who resisted or failed to participate in the drills; * There was was no documented evidence the facility had identified residents who were unwilling or failed to participate in fire drills and made immediate changes to ensure evacuation standards were being met. The need to ensure fire drills were completed and all required components were documented and fire and life safety training for staff was conducted, per the rules, was reviewed with Staff 1 on 08/16/23 and 08/17/23. She acknowledged the findings. Retraining of Proper Fire Drill documentation was held with Environmental Safety staff and a sample was filled out by ESS to ensure that he understands all the components of Fire Drill Documentation. Executive Director will be involved in Fire Drills monthly and will audit Fire Drill Documentation with ESS to ensure all requirements are met and to discuss and resolve any issues that may have occurred during drill. Executive Director will audit drills monthly and ensure these are documented correctly. Retraining of Proper Fire Drill documentation was held with Environmental Safety staff and a sample was filled out by ESS to ensure that he understands all the components of Fire Drill Documentation. Executive Director will be involved in Fire Drills monthly and will audit Fire Drill Documentation with ESS to ensure all requirements are met and to discuss and resolve any issues that may have occurred during drill. Executive Director will audit drills monthly and ensure these are documented correctly. 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 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. Findings include, but are not limited to: On 08/16/23, Staff 1 (ED) was asked to explain the facility's process for providing fire safety training to residents who may be able to retain the information, upon admission and annually. Staff 1 stated there was no documentation of the facility's process and annual training was not provided to residents. No further documentation of resident training was provided. The need to have a process to identify residents who could retain the information and ensure those residents were trained in fire safety procedures upon admission and at least annually was reviewed with Staff 1 on 08/17/23. She acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure residents were instructed 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. Findings include, but are not limited to: On 08/16/23, Staff 1 (ED) was asked to explain the facility's process for providing fire safety training to residents who may be able to retain the information, upon admission and annually. Staff 1 stated there was no documentation of the facility's process and annual training was not provided to residents. No further documentation of resident training was provided. The need to have a process to identify residents who could retain the information and ensure those residents were trained in fire safety procedures upon admission and at least annually was reviewed with Staff 1 on 08/17/23. She acknowledged the findings. Environmental Safety staff trained on completing Fire Safety Training that is to take place upon admission in the memory care with all residents and their family. The Fire Safety Training documentation has been added to the initial move-in paperwork and it is the responsibility of the ESS to ensure this training occurs and is documented within 24 hrs of admission. Business Office Manager will audit to ensure this occurs with each move-in using the updated "move-in checklist". Executive Director will ensure this is completed and sign off on the updated "move-in checklist" within 24 hrs of admission. Environmental Safety staff trained on completing Fire Safety Training that is to take place upon admission in the memory care with all residents and their family. The Fire Safety Training documentation has been added to the initial move-in paperwork and it is the responsibility of the ESS to ensure this training occurs and is documented within 24 hrs of admission. Business Office Manager will audit to ensure this occurs with each move-in using the updated "move-in checklist". Executive Director will ensure this is completed and sign off on the updated "move-in checklist" within 24 hrs of admission. There are no detail notes for this visit.”

“Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C 260, C 295, C 310, and  Z 164. Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C 260, C 295, C 310, and  Z 164. Refer to C 260, C 310 and Z 164 Refer to C 260, C 310 and Z 164 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 C310. 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 C310. Please see our plan of corrections at C310 Please see our plan of corrections at C310 There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The facility had recently renovated eight resident units with hard wood flooring. There were 16 rooms that had not been renovated and had carpet in the units. During a tour of the facility on 08/14/23 through 08/16/23, multiple resident rooms, including but not limited to, room #s 102, 109, 112 and 114 had large dark stains and black scuffs on the carpets. Room 105 had frayed and worn carpet, exposing the flooring beneath the carpet. The rooms in need of carpet repair were discussed with Staff 1 (ED) on 08/17/23. She acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The facility had recently renovated eight resident units with hard wood flooring. There were 16 rooms that had not been renovated and had carpet in the units. During a tour of the facility on 08/14/23 through 08/16/23, multiple resident rooms, including but not limited to, room #s 102, 109, 112 and 114 had large dark stains and black scuffs on the carpets. Room 105 had frayed and worn carpet, exposing the flooring beneath the carpet. The rooms in need of carpet repair were discussed with Staff 1 (ED) on 08/17/23. She acknowledged the findings. Room 105, 103 and 107 carpet replaced with flooring. All rooms with carpet to be replaced with flooring unless resident's decline to relocate for flooring replacement. All rooms with carpet to be placed on a weekly carpet cleaning schedule until carpets can be replaced. Environmental Safety Services to be responsible for ensuring these are cleaned and cleaning is documented on a weekly basis. Executive Director will conduct walk-through of each room at least 1 time per week and will document any flooring or other items needing attention. Room 105, 103 and 107 carpet replaced with flooring. All rooms with carpet to be replaced with flooring unless resident's decline to relocate for flooring replacement. All rooms with carpet to be placed on a weekly carpet cleaning schedule until carpets can be replaced. Environmental Safety Services to be responsible for ensuring these are cleaned and cleaning is documented on a weekly basis. Executive Director will conduct walk-through of each room at least 1 time per week and will document any flooring or other items needing attention. There are no detail notes for this visit.”

“H1517: TA was provided to ensure each individual has privacy in his/her own unit. Refer to C 200. H1517: TA was provided to ensure each individual has privacy in his/her own unit. Refer to C 200. There are no detail notes for this visit.”

“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 C361, C420, C422, and C513. 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 C361, C420, C422, and C513. Refer to POC for C361, C420, C422 and C513 Refer to POC for C361, C420, C422 and C513 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 C 160, C 200, and C 295. 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 C 160, C 200, and C 295. Refer to C 160, C 200 and C 295 Refer to C 160, C 200 and C 295 There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly-hired staff (#16) had the required pre-service dementia training, and 4 of 4 newly-hired staff (#s 13, 14, 15 and 16) completed all required pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to: On 08/15/23 at 10:30 am, Staff 13 (MT), Staff 14 (CG), Staff 15 (CG), and Staff 16's (Dietary Aide) training records were reviewed. During an interview with Staff 1 (ED), the following was identified: 1. Staff 16 hired on 06/13/23, lacked documented evidence of pre-service dementia care training for topics including: * Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms; and * Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: identify and address pain; provide food and fluid; prevent wandering and elopement; and use of a person-centered approach. 2. Staff 13 hired on 07/15/23, Staff 14 hired on 03/15/23, Staff 15 hired on 05/17/23, and Staff 16 hired on 06/13/23, lacked documented evidence of Infectious Disease Prevention training approved by the Department prior to performing job duties. The need to ensure newly-hired staff completed pre-service orientation training prior to beginning their job responsibilities was discussed on 08/16/23 with Staff 1 (ED). She acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly-hired staff (#16) had the required pre-service dementia training, and 4 of 4 newly-hired staff (#s 13, 14, 15 and 16) completed all required pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to: On 08/15/23 at 10:30 am, Staff 13 (MT), Staff 14 (CG), Staff 15 (CG), and Staff 16's (Dietary Aide) training records were reviewed. During an interview with Staff 1 (ED), the following was identified:”

“Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C262, C295, 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. Findings include, but are not limited to: Refer to C260, C262, C295, C302, C303, C310, C330, and C340. Refer to POC for C260, C262, C295, C302, C303, C310, C330, and C340 Refer to POC for C260, C262, C295, 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 C 260 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 C 260 and C 310. Refer to C 260 and C 310 Refer to C 260 and C 310 Based on 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 C 310. Based on 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 C 310. Please see our plan of corrections at C310 Please see our plan of corrections at C310 There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan for 2 of 3 sampled residents (#s 8 and 9) whose service plans were reviewed. Findings include, but are not limited to: Resident 8 and 9's current service plans were reviewed during survey. Each service plan lacked information and 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 resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24.  Staff acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan for 2 of 3 sampled residents (#s 8 and 9) whose service plans were reviewed. Findings include, but are not limited to: Resident 8 and 9's current service plans were reviewed during survey. Each service plan lacked information and 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 resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24.  Staff acknowledged the findings. Resident's surveyed service plans were immediately updated with Nutrition and Hydration plans. All remaining resident's service plans will be updated with Nutrition and Hydration plans as well. SP will ensure all care & health needs, diet texture, nutrition & hydration plan, and preferences are accurate and are provided in the service plan for staff direction. SP team will ensure that the plan is reflective of the daily meal program individualized to each resident and provides clear direction to staff. This will be audited weekly by Lead Med Tech and Food Service Director and as needed to ensure that Service Plan is accurate and correct information is being provided to care staff. Executive Director will be responsible for ensuring this is completed/monitored. Resident's surveyed service plans were immediately updated with Nutrition and Hydration plans. All remaining resident's service plans will be updated with Nutrition and Hydration plans as well. SP will ensure all care & health needs, diet texture, nutrition & hydration plan, and preferences are accurate and are provided in the service plan for staff direction. SP team will ensure that the plan is reflective of the daily meal program individualized to each resident and provides clear direction to staff. This will be audited weekly by Lead Med Tech and Food Service Director and as needed to ensure that Service Plan is accurate and correct information is being provided to care staff. Executive Director will be responsible for ensuring this is completed/monitored. There are no detail notes for this visit.”

“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 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4's records were reviewed, and observations were made during the survey. There was no documented evidence activity evaluations addressed the required components, and that service plans had been individualized to reflect the following: * 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 addressed all required components and individualized activity plans were developed was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. 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 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4's records were reviewed, and observations were made during the survey. There was no documented evidence activity evaluations addressed the required components, and that service plans had been individualized to reflect the following: * 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 addressed all required components and individualized activity plans were developed was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. The findings were acknowledged. Lifestyle Enrichment Director has ensured all activity evaluations are completed and will be meeting with each resident prior to admit or upon admission to ensure that these individualized activity plans are completed upon Admission and included in the service plan. Lifestyle Enrichment Director is responsible for ensuring these are completed and documenting completion. Executive Director and Resident Services Coordinator will audit monthly to ensure these are completed and added to the service plans accurately using PCC. Lifestyle Enrichment Director has ensured all activity evaluations are completed and will be meeting with each resident prior to admit or upon admission to ensure that these individualized activity plans are completed upon Admission and included in the service plan. Lifestyle Enrichment Director is responsible for ensuring these are completed and documenting completion. Executive Director and Resident Services Coordinator will audit monthly to ensure these are completed and added to the service plans accurately using PCC. Based on interview and record review, it was determined the facility failed to ensure all residents were evaluated for activities and/or individualized activity plans were developed for each resident based on their activity evaluation for 3 of 3 sampled residents (#s 8, 9, and 10) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8's service plan offered some information about the resident's interests however, the facility had not completed an evaluation that addressed the following: * Current abilities and skills; * Physical abilities and limitations; and * Adaptations necessary for the resident to participate. The need to ensure the facility evaluated all residents for activities was discussed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24 at 11:40 am.  Staff 1 acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure all residents were evaluated for activities and/or individualized activity plans were developed for each resident based on their activity evaluation for 3 of 3 sampled residents (#s 8, 9, and 10) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure the door to the secured outdoor courtyard was accessible to residents except during nighttime hours or during severe weather and to have a policy for when the doors to the outdoor areas would be locked. Findings include, but are not limited to: On 08/16/23 and 08/17/23 between 9:00 AM and 12:00 PM the weather was clear and dry with a moderate temperature. The door to a secured outdoor courtyard remained locked during that time. In an interview on 08/17/23, Staff 6 (MT) stated the door was locked because it was "too warm" for residents to go outside. Staff 6 stated she did not know the current temperature but guessed "85-90 degrees would be too warm". The policy provided by Staff 1 (ED) regarding resident access to the outdoor courtyard stated, "All care staff are to thoroughly check the courtyards multiple times a shift, at least every 1-2 hours. You are to report to the Med Tech on duty when you have checked the courtyards." Staff 1 stated the facility did not restrict resident access to the courtyard based on time of day but did restrict access based on extreme weather conditions. She acknowledged the current written policy did not clearly define these weather conditions for staff. On 08/17/23 the need to provide access to secured outdoor courtyard areas, except during nighttime hours or during severe weather was discussed with Staff 1. She acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure the door to the secured outdoor courtyard was accessible to residents except during nighttime hours or during severe weather and to have a policy for when the doors to the outdoor areas would be locked. Findings include, but are not limited to: On 08/16/23 and 08/17/23 between 9:00 AM and 12:00 PM the weather was clear and dry with a moderate temperature. The door to a secured outdoor courtyard remained locked during that time. In an interview on 08/17/23, Staff 6 (MT) stated the door was locked because it was "too warm" for residents to go outside. Staff 6 stated she did not know the current temperature but guessed "85-90 degrees would be too warm". The policy provided by Staff 1 (ED) regarding resident access to the outdoor courtyard stated, "All care staff are to thoroughly check the courtyards multiple times a shift, at least every 1-2 hours. You are to report to the Med Tech on duty when you have checked the courtyards." Staff 1 stated the facility did not restrict resident access to the courtyard based on time of day but did restrict access based on extreme weather conditions. She acknowledged the current written policy did not clearly define these weather conditions for staff. On 08/17/23 the need to provide access to secured outdoor courtyard areas, except during nighttime hours or during severe weather was discussed with Staff 1. She acknowledged the findings. A policy has been created stating when courtyard doors are to be opened and locked during extreme weather conditions. Specifics have been added to help guide the staff for consistency and safety.  Signs have been placed on both courtyards stating when the doors will be locked. Carestaff will continue to utilize the alarm system and check the courtyards when alerted to residents outside at all times. Documentation of locking and unlocking courtyard doors will be kept and completed by Med Tech. Lead Med Tech will be responsible for auditing this weekly and Executive Director will audit monthly. A policy has been created stating when courtyard doors are to be opened and locked during extreme weather conditions. Specifics have been added to help guide the staff for consistency and safety.  Signs have been placed on both courtyards stating when the doors will be locked. Carestaff will continue to utilize the alarm system and check the courtyards when alerted to residents outside at all times. Documentation of locking and unlocking courtyard doors will be kept and completed by Med Tech. Lead Med Tech will be responsible for auditing this weekly and Executive Director will audit monthly. There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to ensure residents were not locked outside of their rooms and failed to have individual identifiers to assist residents in recognizing their rooms. Findings include, but are not limited to: The MCC was toured on 08/14/23. Resident rooms 103, 111, 113, and 115 were occupied and lacked any individualized identification to assist residents in recognizing their room. During observations on 08/14/23 through 08/17/23, doors to resident rooms on the MCC unit were observed closed. Further observations revealed many of the closed doors were locked. Multiple residents were observed being unable to go into their rooms without locating staff and asking to be let in. In an interview on 08/15/23 Staff 11 (CG) stated resident's doors were locked to prevent wandering residents going into other's rooms. If residents wanted access to their rooms, they could let staff (who had keys) know and they would let them in. The need to ensure residents were not locked out of their rooms and that rooms had individualized identifiers to assist residents in recognizing their rooms was discussed on 08/17/23 with Staff 1 (ED). She acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure residents were not locked outside of their rooms and failed to have individual identifiers to assist residents in recognizing their rooms. Findings include, but are not limited to: The MCC was toured on 08/14/23. Resident rooms 103, 111, 113, and 115 were occupied and lacked any individualized identification to assist residents in recognizing their room. During observations on 08/14/23 through 08/17/23, doors to resident rooms on the MCC unit were observed closed. Further observations revealed many of the closed doors were locked. Multiple residents were observed being unable to go into their rooms without locating staff and asking to be let in. In an interview on 08/15/23 Staff 11 (CG) stated resident's doors were locked to prevent wandering residents going into other's rooms. If residents wanted access to their rooms, they could let staff (who had keys) know and they would let them in. The need to ensure residents were not locked out of their rooms and that rooms had individualized identifiers to assist residents in recognizing their rooms was discussed on 08/17/23 with Staff 1 (ED). She acknowledged the findings. Executive Director has retrained all staff on leaving doors unlocked unless otherwise stated in the service plan. Service plans have been updated to ensure that ability to use key or alternatives are listed in their service plan. Lifestyle Enrichment Director has replaced all identification boxes to ensure they are on the correct room for the correct resident.  She will be responsible for updating these with new residents and when residents change rooms. Med Tech, Lead Med Tech, Resident Services Coordinator and Executive Director will be responsible for doing walk-throughs daily and ensuring doors are unlocked unless otherwise stated in service plan.  They will be responsible for ensuring the proper identification boxes are outside of the correct room. Executive Director and/or Resident Services Coordinator will be responsible for auditing walk-through's monthly. Executive Director has retrained all staff on leaving doors unlocked unless otherwise stated in the service plan. Service plans have been updated to ensure that ability to use key or alternatives are listed in their service plan. Lifestyle Enrichment Director has replaced all identification boxes to ensure they are on the correct room for the correct resident.  She will be responsible for updating these with new residents and when residents change rooms. Med Tech, Lead Med Tech, Resident Services Coordinator and Executive Director will be responsible for doing walk-throughs daily and ensuring doors are unlocked unless otherwise stated in service plan.  They will be responsible for ensuring the proper identification boxes are outside of the correct room. Executive Director and/or Resident Services Coordinator will be responsible for auditing walk-through's monthly. There are no detail notes for this visit.”