Avamere at St Helens.

“Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 2) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task. Resident 2 moved into the memory care community in 02/2024 with diagnoses including vascular dementia and type II diabetes. During the acuity interview on 06/24/24, Resident 2 was the only resident identified to receive insulin injections from staff. a. Resident 2's MARs, dated 06/01/24 through 06/24/24, were reviewed and revealed insulin had been given by Staff 10 (MT) and Staff 19 (MT) on multiple occasions. Delegation records for Resident 2 were reviewed on 06/26/24 and revealed the following: * Staff 10 and Staff 19's delegation was completed on 04/24/24 and 04/26/24. The delegation records showed there was no documented evidence Staff 10 and 19's skills, abilities and willingness for the delegation tasks; and * There was no rational, based on the competency of the unlicensed staff, for how frequently the unlicensed staff should be supervised and reevaluated. b. The MAR showed a staff's initial of "DaMr" administered the resident's insulin on 06/07/24. Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) were asked the name of employee with initial of "DaMr" during the interview on 06/26/24. They were not able to provide the employee's name and was not able to provide the delegation documentation. The need to ensure unlicensed staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1, Staff 2 and Staff 3 (RN/Health Care Director) on 06/26/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 2) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task. Resident 2 moved into the memory care community in 02/2024 with diagnoses including vascular dementia and type II diabetes. During the acuity interview on 06/24/24, Resident 2 was the only resident identified to receive insulin injections from staff. a. Resident 2's MARs, dated 06/01/24 through 06/24/24, were reviewed and revealed insulin had been given by Staff 10 (MT) and Staff 19 (MT) on multiple occasions. Delegation records for Resident 2 were reviewed on 06/26/24 and revealed the following: * Staff 10 and Staff 19's delegation was completed on 04/24/24 and 04/26/24. The delegation records showed there was no documented evidence Staff 10 and 19's skills, abilities and willingness for the delegation tasks; and * There was no rational, based on the competency of the unlicensed staff, for how frequently the unlicensed staff should be supervised and reevaluated. b. The MAR showed a staff's initial of "DaMr" administered the resident's insulin on 06/07/24. Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) were asked the name of employee with initial of "DaMr" during the interview on 06/26/24. They were not able to provide the employee's name and was not able to provide the delegation documentation. The need to ensure unlicensed staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1, Staff 2 and Staff 3 (RN/Health Care Director) on 06/26/24. They acknowledged the findings.”

“Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed, communicate the interventions to staff, and monitor progress of the conditions to resolution for 1 of 3 sampled residents (#1) reviewed for changes of condition. Resident 1 experienced repeated falls with injuries. Findings include, but are not limited to: Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia. The resident's clinical record, and interviews with staff were conducted during the survey. a. Reviewed "significant change of condition comprehensive assessment" for increased confusion and weakness, dated 04/26/24, and the "MC Level of care and service plan" [quarterly evaluation] dated 05/06/24 and corresponding quarterly service plan dated 05/08/24 indicated the following: * Did not use assistive devices for ambulation; * Was independent with ambulation, bed mobility and transfers; and * Safety checks every 2-3 hours while resident was in his/her room and anticipate needs; * Escort to/from dining room for meals and assist with seating placement; and * Ensure a clutter free environment, bed in low position, personal items and pendant within reach, and non-glare low light at night time. Review of progress notes, dated 04/10/24 through 06/24/24 and interim service plans (ISP's) for the same time period identified the following changes of condition: The resident had seven falls on 04/16/24, 04/22/24, 05/04/24, 05/06/24, 05/08/24, 05/13/24 and 05/22/24. Three of the seven falls had skin and/or head injuries. Although interventions were identified after each subsequent fall there was no documented evidence the facility monitored the fall interventions for effectiveness and the resident continued to have the following additional falls: * 05/30/24 - Unwitnessed fall without apparent injuries; * 05/31/24 - Fall with head injury during ADL care; and * 05/31/24 - Unwitnessed fall (second fall on the same day). Following the 05/30/24 and two falls on 05/31/24, there was no documented evidence the facility determined what resident-specific actions or interventions were needed to try to reduce future falls and communicated the determined actions or interventions to staff. The facility failed to review previous fall interventions for effectiveness and the resident subsequently sustained another unwitnessed fall with injury to the head, left knee and left elbow on 06/07/24 and was sent to the emergency room. Upon return the resident had a decline in ADL ability and required full assistance with dressing, toileting, transfers with one person, on occasion two-person, perform incontinent care only when [s/he] was in bed or on the toilet due to increasing weakness, unsteadiness and declining cognition, and was admitted to hospice seven days later on 06/14/24. On 6/16/24 the resident had another unwitnessed fall without apparent injuries. An ISP written on 06/16/24 revealed no new fall prevention interventions, and the facility failed to review previous fall interventions for effectiveness and/or develop new fall interventions as needed. During observations on 06/24/24 from approximately 9:15 am to 4:20 pm and 06/25/24 from approximately 9:10 am to 4:30 pm, Resident 1 was observed in bed. On 06/26/24, Resident 1 required a two-person transfer to a wheelchair and was escorted to the dining room. During an interview with Staff 10 (MT) on 06/24/24 and Staff 12 (CG) on 06/25/24 it was reported the resident had not returned to baseline since the recent falls, had increased confusion, weakness, had been mostly bedfast since approximately the past two weeks and was admitted to hospice care on 06/14/24. Following the 05/30/24 and two falls on 05/31/24, there was no documented evidence the facility evaluated, determined what resident-specific actions or interventions were needed to try to reduce future falls and communicated the determined actions or interventions to staff. The facility failed to review previous fall interventions for effectiveness and/or develop new fall interventions and the resident continued to have a fall with an injury. The need to ensure resident-specific actions or interventions for changes of condition were determined, documented, and communicated to staff on each shift, were monitored, at least weekly, through resolution and fall interventions were reviewed for effectiveness was discussed with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24 at 3:20 pm. They acknowledged the findings. b. The following skin injuries lacked documented evidence the facility evaluated, determined what resident-specific actions or interventions were needed, communicated the determined actions or interventions to staff, and documented weekly progress through resolution: * 04/16/24 - Right side of head and right ear; * 04/22/24 - Left temple/forehead, top of scalp; * 05/04/24 - Back of the head ("small lump"); * 05/06/24 - Bruise to the right outer ankle and top of scalp; and * 06/07/24 - Back of the head, left knee and left elbow. Observations of the resident on 06/24/24 through 06/26/24 identified multiple areas of previous skin tears on the resident's bilateral legs and arms. The skin injuries were scabbed at the time of survey. During an interview on 06/26/24 at 11:35 am, the above skin areas were discussed with Staff 3 (RN-Health Services Director). Staff 3 reported she did not do any skin monitoring but would look for any documentation regarding weekly monitoring for the above skin injuries. No further information was provided. The need to ensure resident-specific actions or interventions for changes of condition were determined, documented, and communicated to staff on each shift, were monitored, at least weekly, through resolution and fall interventions were reviewed for effectiveness was discussed with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24 at 3:20 pm. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed, communicate the interventions to staff, and monitor progress of the conditions to resolution for 1 of 3 sampled residents (#1) reviewed for changes of condition. Resident 1 experienced repeated falls with injuries. Findings include, but are not limited to: Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia. The resident's clinical record, and interviews with staff were conducted during the survey. a. Reviewed "significant change of condition comprehensive assessment" for increased confusion and weakness, dated 04/26/24, and the "MC Level of care and service plan" [quarterly evaluation] dated 05/06/24 and corresponding quarterly service plan dated 05/08/24 indicated the following: * Did not use assistive devices for ambulation; * Was independent with ambulation, bed mobility and transfers; and * Safety checks every 2-3 hours while resident was in his/her room and anticipate needs; * Escort to/from dining room for meals and assist with seating placement; and * Ensure a clutter free environment, bed in low position, personal items and pendant within reach, and non-glare low light at night time. Review of progress notes, dated 04/10/24 through 06/24/24 and interim service plans (ISP's) for the same time period identified the following changes of condition: The resident had seven falls on 04/16/24, 04/22/24, 05/04/24, 05/06/24, 05/08/24, 05/13/24 and 05/22/24. Three of the seven falls had skin and/or head injuries. Although interventions were identified after each subsequent fall there was no documented evidence the facility monitored the fall interventions for effectiveness and the resident continued to have t”

“Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a timely assessment that documented findings, resident status, and interventions made as a result of the assessment for 3 of 3 sampled residents (#s 1, 3, and 5), who experienced significant changes of condition in weight. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 06/2022 with diagnoses including Alzheimer's dementia and anxiety, and was identified during the acuity interview as having experienced weight loss. The resident's progress notes dated 03/24/24 to 06/24/24 and the "Weights and Vitals Summary" from 02/08/24 to 06/25/24 were reviewed, observations were made, and interviews with staff were conducted. The following was identified: The resident's weight was recorded as follows: * 02/08/24 - 136.2 pounds; * 03/02/24 - 124 pounds; * 05/07/24 - 125.4 pounds; * 06/06/24 - 112.7 pounds; * 06/17/24 - 114.8 pounds; and * 06/25/24 - 120.6 pounds (taken during survey). From 02/08/24 to 03/02/24 the resident lost 12.2 pounds or 8.9% of his/her body weight which constituted a severe weight loss for which a significant change of condition was required. From 05/07/24 to 06/06/24 the resident further lost 13 pounds or 10.3% of his/her body weight which constituted a severe weight loss for which a significant change of condition assessment was required. During an interview at 1:15 pm on 06/26/24, Staff 2 (Regional RN) confirmed no RN assessment had been completed. The resident was observed at two snack passes and for three meals. S/he consumed 100% of the snacks, 10% of one meal, and 100% of the other two meals. She/he was observed to require 40 minutes to over one hour to complete his/her meals. Staff were observed to assist him/her with feeding. S/he would attempt to feed him/herself using his/her fingers; however this was unsuccessful as his/her diet was pureed texture. The need to ensure a timely RN assessment was completed which included resident status, findings, and interventions made as a result of the assessment for all significant changes of condition was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 on 06/26/24. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a timely assessment that documented findings, resident status, and interventions made as a result of the assessment for 3 of 3 sampled residents (#s 1, 3, and 5), who experienced significant changes of condition in weight. Findings include, but are not limited to:”

“The findings of the re-licensure survey, conducted 06/24/24 through 06/26/24, 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 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 06/24/24 through 06/26/24, 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 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 re-visit to the re-licensure survey of 06/26/24, conducted 10/21/24 through 10/23/24, are documented in this report. It was determined the facility was in substantial compliance with 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. The findings of the first re-visit to the re-licensure survey of 06/26/24, conducted 10/21/24 through 10/23/24, are documented in this report. It was determined the facility was in substantial compliance with 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.”

“Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the relicensure survey, conducted 06/24/24 through 06/26/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope, severity, and number of citations. Refer to deficiencies in the report. Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the relicensure survey, conducted 06/24/24 through 06/26/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope, severity, and number of citations. Refer to deficiencies in the report.”

“Based on observation and interview, it was determined the facility failed to ensure residents' right to a safe and homelike environment and to receive services in a manner that protects privacy and dignity for 3 of 3 sampled residents (#s 1, 2 and 3) and multiple unsampled residents. Findings include, but are not limited to: 1. Resident 2 and Resident 3 moved into the memory care facility in 02/2024 and 06/2022 with diagnoses including vascular dementia and Alzheimer's dementia, respectively. a. Resident 2 and 3's most current service plans were reviewed and observations were conducted from 06/24/24 to 06/25/24 and the following was identified: * The residents' service plan indicated s/he preferred to be called by their first name. Staff were observed multiple times calling the resident "sweetheart" and "honey". b. During the survey, staff were observed communicating details about unsampled residents' care needs and/or status over their walkie-talkies, using individual resident's names in the dining room and/or common areas. On 06/24/24 at 12:46 pm, staff were observed communicating details about Resident 3's care needs and status over their walkie-talkies in the dining room where other residents were present, using his/her name. The need to ensure the resident's right to privacy and dignity was upheld was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/25/24 and 06/26/24. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure residents' right to a safe and homelike environment and to receive services in a manner that protects privacy and dignity for 3 of 3 sampled residents (#s 1, 2 and 3) and multiple unsampled residents. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure resident-to-resident altercations, elopement, and inappropriate verbal and physical behaviors were immediately reported to the local SPD or AAA office as suspected abuse and the facility failed to ensure unwitnessed falls with injuries were reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the falls with injuries were not the result of abuse for 2 of 3 sampled residents (#s 1 and 2) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the memory care community in 02/2024 with diagnoses including vascular dementia. The resident's service plan, dated 06/05/24, incident investigation reports, progress notes from 03/18/24 through 06/23/24, observations of the resident, and interviews with care staff during the survey indicated the resident was confused and used inappropriate language with a resident. a. The resident's clinical record revealed the following: * 06/08/24 - "Resident reached out to touch another residents private area..."; * 06/18/24 - "Making inappropriate sexual comments towards a ... resident and trying to grope [his/her] crotch."; * 06/20/24 - "very inappropriate with a ... resident." "...resident kept asking [him/her] to leave [him/her] alone...yelling at [him/her]."; * 06/21/24 - "resident was touching another resident on [his/her] legs and arm even after the [resident] asked [him/her] to stop. [the resident] continued." On 06/24/24 at 2:15 pm, Staff 2 (Regional RN) reviewed the above documentation and Staff 2 reported the incidents should have been investigated. The survey requested Staff 2 to report to the local SPD office. On 06/25/24 at 10:47 am, confirmation the reports had been sent to the local SPD office was provided. b. The resident's clinical record revealed the following: * 03/22/24 - The resident was involved a resident to resident altercation in which a resident "grabbed onto [his/her] shoulder and wheelchair and then pushed [him/her] into the door."; and * The incident report, dated on 03/22/24, indicated the incident had been reported to "APS." However, there was no documented evidence the incident was reported to the local SPD office. The surveyor requested Staff 1 (Interim ED/Regional Director Of Operations) and Staff 2 report the incident to the local SPD office. On 06/26/24 at 9:10 am, confirmation the reports had been sent to the local SPD office was provided. c. The resident's clinical record revealed the following: * 06/09/24 - The resident was "out in the parking lot." Staff documented on the 06/09/24 incident report that the incident "will be placed [with] APS." However, there was no documented evidence the incident was reported to the local SPD office. The surveyor requested Staff 1 and Staff 2 report the incident to the local SPD office. On 06/26/24 at 9:10 am, confirmation the reports had been sent to the local SPD office was provided. The need to ensure all suspected incidents were immediately reported to local SPD office was discussed with Staff 1 and Staff 2 on 06/25/24. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure resident-to-resident altercations, elopement, and inappropriate verbal and physical behaviors were immediately reported to the local SPD or AAA office as suspected abuse and the facility failed to ensure unwitnessed falls with injuries were reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the falls with injuries were not the result of abuse for 2 of 3 sampled residents (#s 1 and 2) whose incidents 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 initial evaluation addressed all the required elements for 1 of 1 newly admitted resident (# 4) whose initial evaluation was reviewed. Findings include, but are not limited to: Resident 4 moved into the memory care community in 05/2024 with diagnoses including dementia. The resident's initial evaluation was reviewed and it failed to address the following required elements: * Interests, hobbies, social, leisure activities; * Spiritual, cultural preferences and traditions; * Physical health status including visits to health practitioners, emergency room, hospital or nursing facility in the past years and vital signs if indicated by diagnosis, health problems or medications; * Mental health issues including history of treatment and effective non-drug interventions; * Personality including how the person copes with change or challenging situations; * List of treatments including type, frequency and level of assistance needed; * Complex medication regimen; * Recent losses; * Unsuccessful prior placements; and * Environmental factors that impact the resident's behaviors including, but not limited to noise, lighting, room temperature. The need to ensure the initial evaluation included all required elements was discussed with Staff 1 (Interim ED/Regional Director of Operations) on 06/25/24. Staff acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure an initial evaluation addressed all the required elements for 1 of 1 newly admitted resident (# 4) whose initial evaluation was reviewed. Findings include, but are not limited to: Resident 4 moved into the memory care community in 05/2024 with diagnoses including dementia. The resident's initial evaluation was reviewed and it failed to address the following required elements: * Interests, hobbies, social, leisure activities; * Spiritual, cultural preferences and traditions; * Physical health status including visits to health practitioners, emergency room, hospital or nursing facility in the past years and vital signs if indicated by diagnosis, health problems or medications; * Mental health issues including history of treatment and effective non-drug interventions; * Personality including how the person copes with change or challenging situations; * List of treatments including type, frequency and level of assistance needed; * Complex medication regimen; * Recent losses; * Unsuccessful prior placements; and * Environmental factors that impact the resident's behaviors including, but not limited to noise, lighting, room temperature. The need to ensure the initial evaluation included all required elements was discussed with Staff 1 (Interim ED/Regional Director of Operations) on 06/25/24. Staff acknowledged the findings.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, and/or were implemented for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 06/2022 with diagnoses including Alzheimer's dementia, anxiety, and a history of falls. The resident's service plan available to staff, dated 06/11/24, and Interim Service Plans were reviewed, observations of the resident were made, and interviews with staff were conducted. The resident's service plan was not reflective and/or was not implemented in the following areas: * Staff assistance with toileting every two to three hours; * Transfer assistance; and * Communication abilities, including ability to verbalize basic wants and needs around toileting, hunger, and thirst. The need to ensure service plans were reflective and implemented was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. 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' needs, provided clear direction to staff regarding the delivery of services, and/or were implemented for 3 of 3 sampled residents (#s 1, 2 and 3) 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 to provide a safe, sanitary and comfortable environment for 1 of 2 sampled residents (# 1) who received incontinent care and multiple unsampled residents who received dining services. Findings include, but are not limited to: 1. Three meal services and three snack services were observed from 06/24/24 to 06/26/24. The following was identified: * Residents, many who were observed to eat with their hands, were not offered hand hygiene prior to meals or snacks; * Direct care staff serving meals were not observed with a protective barrier between the food and their potentially contaminated clothing; * Direct care staff were observed wearing single use gloves during dining services; however they did not perform hand hygiene prior to donning gloves and after disposing of the gloves; * Staff were observed delivering meals, beverages, desserts, and snacks to residents' rooms without covering the food or beverage to protect from contamination; * An unsampled resident was observed assisting a caregiver to set the dining room tables, touching cups, bowls, and silverware with his/her hands without first performing hand hygiene; and * Silverware was set on the dining room tables several hours before meal service. The need to ensure the facility maintained effective infection prevention and control protocols was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 1 of 2 sampled residents (# 1) who received incontinent care and multiple unsampled residents who received dining services. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to: Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia, atherosclerotic heart disease and hypothyroidism. Review of Resident 1's current physician orders, MARs from 05/01/24 through 06/24/24 identified the following: * The resident was prescribed Levothyroxine Sodium oral tablet 112 mcg, give one tablet by mouth in the morning (for hypothyroidism); and * From 05/03/24 to 06/26/24 the resident was not administered the medication on 20 separate occasions because the medication was not available. During an interview and observation of the medication cart on 06/26/24 at 11:20 am with Staff 3 (RN-Healthcare Director), it was confirmed the medication was not in the medication cart. During an interview with Staff 4 (LPN - Assist Healthcare Director) on 06/26/24 it was reported " we are having pharmacy issues, [s/he] has VA [Veterans Administration], we faxed them but haven't received a response. When this happened before we contacted the POA [power of attorney] to authorize payment to use our pharmacy, which we did but then [s/he] ran out again. [S/he] is now on hospice and I have talked to them about the medication needing to be refilled. We are just having a hard time getting it." The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN), and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings. Prior to survey exit, Staff 2 confirmed the medication would be available the following day. Based on observation, interview, and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to: Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia, atherosclerotic heart disease and hypothyroidism. Review of Resident 1's current physician orders, MARs from 05/01/24 through 06/24/24 identified the following: * The resident was prescribed Levothyroxine Sodium oral tablet 112 mcg, give one tablet by mouth in the morning (for hypothyroidism); and * From 05/03/24 to 06/26/24 the resident was not administered the medication on 20 separate occasions because the medication was not available. During an interview and observation of the medication cart on 06/26/24 at 11:20 am with Staff 3 (RN-Healthcare Director), it was confirmed the medication was not in the medication cart. During an interview with Staff 4 (LPN - Assist Healthcare Director) on 06/26/24 it was reported " we are having pharmacy issues, [s/he] has VA [Veterans Administration], we faxed them but haven't received a response. When this happened before we contacted the POA [power of attorney] to authorize payment to use our pharmacy, which we did but then [s/he] ran out again. [S/he] is now on hospice and I have talked to them about the medication needing to be refilled. We are just having a hard time getting it." The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN), and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings. Prior to survey exit, Staff 2 confirmed the medication would be available the following day.”

“Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, had resident-specific parameters for PRN medications and clear instructions to staff for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the memory care community in 02/2024 with diagnoses including vascular dementia and type II diabetes. Resident 2's 06/01/24 through 06/24/24 MAR were reviewed and revealed the following: * Resident 2's MAR included to administer Glucose oral tablets "as needed for hypoglycemia." There were no resident-specific parameters including when to administer the PRN medication. The need to ensure medications had resident-specific parameters for PRN medications and clear instructions to staff was reviewed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, had resident-specific parameters for PRN medications and clear instructions to staff for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were administered only for specific medical symptoms and after non-drug interventions had been attempted and were ineffective, for 3 of 3 sampled residents (#s 1, 2 and 3) who had an order for PRN psychoactive medication. Findings include, but are not limited to: 1. Resident 2 moved into the memory care facility in 02/2024 with diagnoses including vascular dementia, psychotic disturbance and anxiety. Review of Resident 2's MAR, dated 06/01/24 through 06/24/24, and 05/18/24 through 06/23/24 progress notes revealed the following: * The resident was prescribed hydroxyzine 25 mg for anxiety and Olanzapin 2.5 mg for agitation as needed; * The MAR did not provide instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation or anxiety behaviors for which staff could consider administering the medication; and * Staff failed to consistently document non-drug interventions had been attempted with ineffective results prior to administering the medication on three occasions. On 06/26/24, Resident 2's record was reviewed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN). Providing specific medical parameters including signs and symptoms for the administration of PRN psychotropic medications and to attempt non-pharmacological interventions prior to administering the PRN psychoactive medications was reviewed. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were administered only for specific medical symptoms and after non-drug interventions had been attempted and were ineffective, for 3 of 3 sampled residents (#s 1, 2 and 3) who had an order for PRN psychoactive medication. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident, including sufficient staff to meet the fire safety evacuation standards. Findings include, but are not limited to: The facility was licensed as a Memory Care with a capacity of 28 beds. a. On 06/24/24 during the entrance conference, survey requested a facility staffing policy or a tool to determine number of caregiving staff needed to provide scheduled and unscheduled residents' care needs. The facility acuity-based staffing tool (ABST) for all residents was reviewed during the survey. During the acuity interview on 06/26/24 and subsequent resident record reviews, the following care needs were identified: * The facility had a census of 17 residents; * Three residents required two-person transfers; * One resident required one-person assistance with all transfers; * Six residents were identified as heavy care requiring full assistance with ADL's; * Two residents were on hospice; * Two residents needed one-on-one meal assistance; and * Two residents had incidents of recent elopement. The facility ABST was not accurately being used to determine the correct staffing minutes in multiple ADL areas for sampled Residents 1, 2 and 3 who required 1:1 meal assistance, two person ADL care needs, aggressive behaviors which resulted in multiple resident to resident altercations, and/or had multiple falls with injuries. Refer to C 361 b. The facility's staffing plan, posted during the survey, showed the following: * Day shift - 2 Caregivers and 1 Med Tech * Evening shift - 2.5 Caregivers and 1 Med Tech; and * Night shift - 1 Caregivers and 1 Med Tech. Observations and interviews conducted between 06/24/24 and 06/26/24 showed the following: * Multiple residents needed full meal assistance in their apartments or dining room, two-person transfers, toileting, and/or bathing; * Observation of ADL care for Resident 1 on 06/26/24, the caregivers were discussing needing to request a third caregiver. In an interview regarding Resident 1's care needs requiring three caregivers, Staff 6 (RCC) stated, we can't that would leave no one on the floor with the other residents." * During an interview on 06/25/24, Staff 12 (CG) reported "We need more people, we can't provide care timely. Like for [Resident 1] we need two people and there isn't anyone to help, especially during breaks when there is only two people on the floor. Sometimes we need three people to help transfer [Resident 1]. Three days per week we only have two caregivers and the Med Tech, it's not enough." c. Review of the call light report from 05/15/24 through 06/26/24 identified 43 call response times were in excess of 30 minutes through nine hours. The call light report also identified 4 residents who had been identified during survey as heavy care requiring full assistance with ADL's, had multiple falls with injuries, were on hospice, and/or had a dementia diagnosis who experienced excessive call light response times. The facility's failure to ensure staff adequate in number to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident, including sufficient staff to meet the fire safety evacuation standards. Findings include, but are not limited to: The facility was licensed as a Memory Care with a capacity of 28 beds. a. On 06/24/24 during the entrance conference, survey requested a facility staffing policy or a tool to determine number of caregiving staff needed to provide scheduled and unscheduled residents' care needs. The facility acuity-based staffing tool (ABST) for all residents was reviewed during the survey. During the acuity interview on 06/26/24 and subsequent resident record reviews, the following care needs were identified: * The facility had a census of 17 residents; * Three residents required two-person transfers; * One resident required one-person assistance with all transfers; * Six residents were identified as heavy care requiring full assistance with ADL's; * Two residents were on hospice; * Two residents needed one-on-one meal assistance; and * Two residents had incidents of recent elopement. The facility ABST was not accurately being used to determine the correct staffing minutes in multiple ADL areas for sampled Residents 1, 2 and 3 who required 1:1 meal assistance, two person ADL care needs, aggressive behaviors which resulted in multiple resident to resident altercations, and/or had multiple falls with injuries. Refer to C 361 b. The facility's staffing plan, posted during the survey, showed the following: * Day shift - 2 Caregivers and 1 Med Tech * Evening shift - 2.5 Caregivers and 1 Med Tech; and * Night shift - 1 Caregivers and 1 Med Tech. Observations and interviews conducted between 06/24/24 and 06/26/24 showed the following: * Multiple residents needed full meal assistance in their apartments or dining room, two-person transfers, toileting, and/or bathing; * Observation of ADL care for Resident 1 on 06/26/24, the caregivers were discussing needing to request a third caregiver. In an interview regarding Resident 1's care needs requiring three caregivers, Staff 6 (RCC) stated, we can't that would leave no one on the floor with the other residents." * During an interview on 06/25/24, Staff 12 (CG) reported "We need more people, we can't provide care timely. Like for [Resident 1] we need two people and there isn't anyone to help, especially during breaks when there is only two people on the floor. Sometimes we need three people to help transfer [Resident 1]. Three days per week we only have two caregivers and the Med Tech, it's not enough." c. Review of the call light report from 05/15/24 through 06/26/24 identified 43 call response times were in excess of 30 minutes through nine hours. The call light report also identified 4 residents who had been identified during survey as heavy care requiring full assistance with ADL's, had multiple falls with injuries, were on hospice, and/or had a dementia diagnosis who experienced excessive call light response times. The facility's failure to ensure staff adequate in number to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings.”

“Based on observation, interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that addressed all the following activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care for 3 of 3 sampled residents (#s 1, 2 and 3) whose ABST were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the memory care facility in 02/2024 with diagnoses including vascular dementia, psychotic disturbance and anxiety. The resident's ABST, last updated 06/19/24, service plan available to staff dated 06/05/24, and Interim Service Plans from 05/24/24 to 06/08/24 were reviewed, interviews with staff were conducted revealed the following: * The resident's ABST failed to capture the amount of staff time needed to provide care in the following areas; and * Resident 2 had zero minutes added for assisting with leisure activities, non-drug interventions for behaviors and grooming such as nail care and brushing hair assistance on the ABST. Observation of the resident, interviews with staff and review of the 06/05/24 service plan revealed staff provided leisure activities, non-drug interventions for behaviors and grooming assistance as the resident required. The need to ensure all required ADLs on the ABST with the amount of staff time needed to provide care was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings. Based on observation, interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that addressed all the following activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care for 3 of 3 sampled residents (#s 1, 2 and 3) whose ABST were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records from 12/2023 through 05/2024 were reviewed with Staff 5 (Director Environmental) on 06/25/24 and the following was identified: a. Fire drill records were being conducted in the assisted living which was a separate license from the attached memory care facility. The memory care facility lacked documentation of fire drills being conducted on alternating months which included the following required elements: * Date and time of fire drill; * Location of fire origin; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Staff members on duty and participating; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. b. Fire and life safety instruction for staff on alternating months lacked documentation of which staff were in attendance. The requirements for providing and documenting a written record of fire drills, fire and life safety instruction and staff in attendance was discussed with Staff 5 on 06/25/24, Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records from 12/2023 through 05/2024 were reviewed with Staff 5 (Director Environmental) on 06/25/24 and the following was identified: a. Fire drill records were being conducted in the assisted living which was a separate license from the attached memory care facility. The memory care facility lacked documentation of fire drills being conducted on alternating months which included the following required elements: * Date and time of fire drill; * Location of fire origin; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Staff members on duty and participating; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. b. Fire and life safety instruction for staff on alternating months lacked documentation of which staff were in attendance. The requirements for providing and documenting a written record of fire drills, fire and life safety instruction and staff in attendance was discussed with Staff 5 on 06/25/24, Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed at least annually in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire, and a written record of fire safety training was kept. Findings include, but are not limited to: In an interview on 06/25/24, Staff 5 (Director Environmental) was asked how the facility provided fire safety upon admission and annual re-training on fire safety for residents. Staff 5 reported he thought "someone from marketing does this with the them, but she's on vacation now." Surveyor requested Staff 5 follow-up and see if the documentation could be provided. No further information was provided. The need to ensure the residents were re-instructed upon move in and at least annually on safety procedures and the fire and life safety instruction was documented, was discussed with Staff 5 on 06/25/24 and Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed at least annually in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire, and a written record of fire safety training was kept. Findings include, but are not limited to: In an interview on 06/25/24, Staff 5 (Director Environmental) was asked how the facility provided fire safety upon admission and annual re-training on fire safety for residents. Staff 5 reported he thought "someone from marketing does this with the them, but she's on vacation now." Surveyor requested Staff 5 follow-up and see if the documentation could be provided. No further information was provided. The need to ensure the residents were re-instructed upon move in and at least annually on safety procedures and the fire and life safety instruction was documented, was discussed with Staff 5 on 06/25/24 and Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure the interior of the building was maintained clean and was free from unpleasant odors. Findings include, but are not limited to: The interior of the building was toured at 9:05 am on 06/24/24. The following was identified: * There was a pervasive, unpleasant odor in the facility hallways and the common room that did not dissipate during the survey; * The interior and exterior of the kitchenette cabinets, drawers, and refrigerator had a buildup of food debris, splashes, spills, dust; and * The carpet was stained in multiple areas in the hallways and common room. The need to ensure the facility was maintained clean and free from unpleasant odors was discussed with Staff 1 (Interim ED/Regional Director of Operations) on 06/26/24. She acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure the interior of the building was maintained clean and was free from unpleasant odors. Findings include, but are not limited to: The interior of the building was toured at 9:05 am on 06/24/24. The following was identified: * There was a pervasive, unpleasant odor in the facility hallways and the common room that did not dissipate during the survey; * The interior and exterior of the kitchenette cabinets, drawers, and refrigerator had a buildup of food debris, splashes, spills, dust; and * The carpet was stained in multiple areas in the hallways and common room. The need to ensure the facility was maintained clean and free from unpleasant odors was discussed with Staff 1 (Interim ED/Regional Director of Operations) on 06/26/24. She acknowledged the findings.”

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

“Concerns were identified and the facility was provided with technical assistance in the following areas: H 1517: OAR 411-004-0020(2)(d): Individual Privacy: Own Unit. (d) Each individual has privacy in his or her own unit. Concerns were identified and the facility was provided with technical assistance in the following areas: H 1517: OAR 411-004-0020(2)(d): Individual Privacy: Own Unit. (d) Each individual has privacy in his or her own unit. There are no detail notes for this visit.”

“During the survey, concerns were identified in the following areas and the facility was provided with technical assistance: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. During the survey, concerns were identified in the following areas and the facility was provided with technical assistance: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. 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 C 150, C 200, C 231, C 295, C 360, C 361, C 420, C 422 and C 513. Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 150, C 200, C 231, C 295, C 360, C 361, C 420, C 422 and C 513. Refer to C150, C200, C231, C295, C360, C361, C420, C422, C513 for POC Refer to C150, C200, C231, C295, C360, C361, C420, C422, C513 for POC There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 8, 11, 16, and 18) completed pre-service dementia care training that addressed required topics and that 3 of 4 long-term staff (#s 7, 12, and 17) completed a total of 16 hours of annual in-service training. Findings include, but are not limited to: Staff training records were reviewed with Staff 20 (Business Office Manager) at 12:20 pm on 06/26/24. The following was identified: a. There was no documented evidence Staff 8 (MT), hired 05/08/24, Staff 11 (CG), hired 04/25/24, Staff 16 (CG), hired 04/03/24, and Staff 18 (CG), hired 03/25/24, completed all required dementia care pre-service orientation training 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; * 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, and use a person-centered approach; * How to provide personal care to a resident with dementia; and * The use of supportive devices with restraining qualities in memory care communities. b. There was no documented evidence Staff 7 (CG), hired 04/16/21, Staff 12 (CG), hired 08/30/21, Staff 17 (CG), hired 07/13/21 completed 16 hours of annual in-service training. The need to ensure staff completed all required pre-service orientation training and annual in-service training was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 8, 11, 16, and 18) completed pre-service dementia care training that addressed required topics and that 3 of 4 long-term staff (#s 7, 12, and 17) completed a total of 16 hours of annual in-service training. Findings include, but are not limited to: Staff training records were reviewed with Staff 20 (Business Office Manager) at 12:20 pm on 06/26/24. The following was identified: a. There was no documented evidence Staff 8 (MT), hired 05/08/24, Staff 11 (CG), hired 04/25/24, Staff 16 (CG), hired 04/03/24, and Staff 18 (CG), hired 03/25/24, completed all required dementia care pre-service orientation training 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; * 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, and use a person-centered approach; * How to provide personal care to a resident with dementia; and * The use of supportive devices with restraining qualities in memory care communities. b. There was no documented evidence Staff 7 (CG), hired 04/16/21, Staff 12 (CG), hired 08/30/21, Staff 17 (CG), hired 07/13/21 completed 16 hours of annual in-service training. The need to ensure staff completed all required pre-service orientation training and annual in-service training was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.”

“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 270, C 280, C 282, C 303, C 310 and C 330. 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 270, C 280, C 282, C 303, C 310 and C 330. Refer to C252, C260, C270, C280, C282, C303, C310 C330 for POC Refer to C252, C260, C270, C280, C282, C303, C310 C330 for POC There are no detail notes for this visit.”

“Based on observation, 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 1 of 3 sampled residents (#1) whose service plan was reviewed. Findings include, but are not limited to: Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia, and was identified during the acuity interview as needing meal assistance. Review of the previous six months of "Weights and Vitals Summary" indicated the resident had a severe weight loss on 06/17/24. Resident 1's current service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident in the following areas: * Eating status and assistance needed; * Dietary needs including puree diet; * Use of a divided plate, two handled cup with a lid and a cup with a lid and straw; and * Weight loss and interventions. 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 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings. Based on observation, 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 1 of 3 sampled residents (#1) whose service plan was reviewed. Findings include, but are not limited to: Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia, and was identified during the acuity interview as needing meal assistance. Review of the previous six months of "Weights and Vitals Summary" indicated the resident had a severe weight loss on 06/17/24. Resident 1's current service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident in the following areas: * Eating status and assistance needed; * Dietary needs including puree diet; * Use of a divided plate, two handled cup with a lid and a cup with a lid and straw; and * Weight loss and interventions. 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 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure each resident was evaluated for activities addressing all required elements, develop an individualized activity plan based on their activity evaluation, and provide a selection of daily structured and unstructured activities for 3 of 3 sampled residents (#s 1, 2, and 3) whose evaluations and service plans were reviewed. Findings include, but are not limited to: Observations of Residents 1, 2, and 3 were conducted from 06/24/24 to 06/26/24. Staff were not observed to provide a selection of daily structured and unstructured activities for Residents 1, 2, and 3. The most recent quarterly evaluations and current service plans were reviewed for Residents 1, 2, and 3. The following was identified: a. There was no documented evidence an activity evaluation had been completed that addressed all of the following: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. b. There was no documented evidence an individualized plan was developed for each resident. The need to ensure activity evaluations were completed, individualized activity plans were developed, and a selection of daily structured and unstructured activities were provided for residents was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure each resident was evaluated for activities addressing all required elements, develop an individualized activity plan based on their activity evaluation, and provide a selection of daily structured and unstructured activities for 3 of 3 sampled residents (#s 1, 2, and 3) whose evaluations and service plans were reviewed. Findings include, but are not limited to: Observations of Residents 1, 2, and 3 were conducted from 06/24/24 to 06/26/24. Staff were not observed to provide a selection of daily structured and unstructured activities for Residents 1, 2, and 3. The most recent quarterly evaluations and current service plans were reviewed for Residents 1, 2, and 3. The following was identified: a. There was no documented evidence an activity evaluation had been completed that addressed all of the following: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. b. There was no documented evidence an individualized plan was developed for each resident. The need to ensure activity evaluations were completed, individualized activity plans were developed, and a selection of daily structured and unstructured activities were provided for residents was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.”

“Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the facility failed to post the name of the designated person in charge by shift or whenever the Administrator is out of the facility. Findings include, but are not limited to: On 06/11/24 at 4:43 pm and on 06/12/24 at 9:04 am, the Compliance Specialist entered the facility and did not observe a licensed administrator to be onsite. In separate interviews on 06/11/24, Staff 1 (RCC), Staff 5 (CG), Staff 6 (MT), Staff 7 (RCC), Staff 8 (CG), and Staff 9 (CG) stated the following: * At 4:45pm: "There is no administrator for the [memory care]." * The previous administrator stepped down two weeks ago. * If [s/he] doesn't know who's the manager on duty, s/he will go to the med tech. * At 5:00 pm: "[Staff 4] is available via phone [and] not scheduled to be onsite this week." * At 5:30pm: "The Administrator is [Staff 3]." * There was no information provided on who was to fill in when Staff 2 (former MCC Administrator stepped down. *At 5:45 pm, since Staff 2 stepped down, s/he can't say there's been a licensed administrator onsite for 40 hours. In an interview on 06/11/24 at 6:55 pm, Staff 4 (Regional Director of Operations) stated the following: * Staff 3 (Administrator) notified the Department via email on 05/21/24 that s/he would be temporarily absent starting on 05/22/24. * Staff 3 went out on leave on 05/22/24. * Staff 3 had an exception [to be administrator] for ALF and MCC. * S/He was in charge when Staff 3 went out on leave. * Staff 2 stepped down on 05/28/24. * S/He is onsite every week. * Last week, s/he was onsite for a full three days and partially on a fourth day and completed two evaluations for assisted living and one evalution for memory care. When asked what actions were taken with facility staff when Staff 3 stepped down, Staff 4 was unable to provide an answer. On 06/11/24 at 7:35 pm, there were no waivers or exceptions granted or provided that allowed the facility to operate without an administrator. On 06/11/24 at approximately 4:45 pm, it was observed in both the ALF and MCC, the facility's required Designated Person in Charge signage stated "Health Care Coordinator" but lacked the name of the staff member in charge. By 7:35 pm, the signage was updated with a name. On 06/12/24 at 9:05 am, it was observed there was no administrator onsite and the assisted living facility's required Designated Person in Charge signage said "Health Care Coordinator" but lacked the name of the staff member in charge. At 9:16 am, there was no administrator onsite and the MCC facility's required Designated Person in Charge signage was blank. In separate interviews on 06/12/24, Staff 10 (MT), Staff 11 (CG), Staff 12 (CG) and Staff 13 (LPN) stated the following: * S/He identified the RCCs or nurses as the person in charge. * At 9:16 am: "[Staff 2 (former MCC Admin)] stepped down in the end of May." * S/He stated the RCC was in charge when Staff 2 stepped down. * Staff 4 was in the MCC last week when s/he asked about the service plan binder. * S/He did not have Staff 4's contact information. * The previous memory administrator, before Staff 2, left that role in February 2024. * There was no communication to care staff who was filling in as interim Administrator. * Staff 4 spent his/her time last week in Staff 3's office. * Before [Staff 3] went out on leave, s/he sent an email to facility management who would be in charge, but nothing was communicated to the caregivers. * Last week [Staff 4] was onsite three to four days for approximately 10 hour days. In an interview on 06/12/24 at 10:38 am, Witness 1 and Witness 2 stated s/he has not seen any manager in the MCC during their visits. In an interview on 06/12/24 at 11:13 am, Witness 3 and Witness 4 (family members) stated they are in the facility once-to-twice per week. If s/he had concerns, they would go the front desk for help. The MT is usually the staff member in charge unless the "front office door is open, then [s/he would] go to them. But they had a change and don't know who is in charge now." On 06/12/24 at 12:00 pm, Staff 4 was observed to be onsite in the MCC. CS requested Staff 4 provide a written schedule of his/her time onsite. In an email, dated 06/12/24, Staff 4 indicated s/he worked "remote" during the week "05/22- 05/28". In an interview on 06/13/24 at 9:00 am, Witness 5 (ODHS OPA) stated the following: * S/He was notified on or about 05/21/24 via email that Staff 3 will be out and Staff 4 would take over. * S/He was with the understanding that Staff 4 would be onsite 40 hours. * S/He did not have the paperwork required of and for times when a new administrator is stepping into the administrator role for Staff 2. On 06/13/24 at 9:35 am, via telephone, these findings were reviewed with Staff 4. Staff 4 stated his/her team was onsite and s/he was available by phone. Verbal Plan of Correction: The Interim Administrator will be onsite in the community 40-hours until the Executive Director returns. Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the facility failed to post the name of the designated person in charge by shift or whenever the Administrator is out of the facility. Findings include, but are not limited to: On 06/11/24 at 4:43 pm and on 06/12/24 at 9:04 am, the Compliance Specialist entered the facility and did not observe a licensed administrator to be onsite. In separate interviews on 06/11/24, Staff 1 (RCC), Staff 5 (CG), Staff 6 (MT), Staff 7 (RCC), Staff 8 (CG), and Staff 9 (CG) stated the following: * At 4:45pm: "There is no administrator for the [memory care]." * The previous administrator stepped down two weeks ago. * If [s/he] doesn't know who's the manager on duty, s/he will go to the med tech. * At 5:00 pm: "[Staff 4] is available via phone [and] not scheduled to be onsite this week." * At 5:30pm: "The Administrator is [Staff 3]." * There was no information provided on who was to fill in when Staff 2 (former MCC Administrator stepped down. *At 5:45 pm, since Staff 2 stepped down, s/he can't say there's been a licensed administrator onsite for 40 hours. In an interview on 06/11/24 at 6:55 pm, Staff 4 (Regional Director of Operations) stated the following: * Staff 3 (Administrator) notified the Department via email on 05/21/24 that s/he would be temporarily absent starting on 05/22/24. * Staff 3 went out on leave on 05/22/24. * Staff 3 had an exception [to be administrator] for ALF and MCC. * S/He was in charge when Staff 3 went out on leave. * Staff 2 stepped down on 05/28/24. * S/He is onsite every week. * Last week, s/he was onsite for a full three days and partially on a fourth day and completed two evaluations for assisted living and one evalution for memory care. When asked what actions were taken with facility staff when Staff 3 stepped down, Staff 4 was unable to provide an answer. On 06/11/24 at 7:35 pm, there were no waivers or exceptions granted or provided that allowed the facility to operate without an administrator. On 06/11/24 at approximately 4:45 pm, it was observed in both the ALF and MCC, the facility's required Designated Person in Charge signage stated "Health Care Coordinator" but lacked the name of the staff member in charge. By 7:35 pm, the signage was updated with a name. On 06/12/24 at 9:05 am, it was observed there was no administrator onsite and the assisted living facility's required Designated Person in Charge signage said "Health Care Coordinator" but lacked the name of the staff member in charge. At 9:16 am, there was no administrator onsite and the MCC facility's required Designated Person in Charge signage was blank. In separate interviews on 06/12/24, Staff 10 (MT), Staff 11 (CG), Staff 12 (CG) and Staff 13 (LPN) stated the following: * S/He identified the RCCs or nurses as the person in charge. * At 9:16 am: "”

“Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the facility failed to provide a full-time administrator to be onsite 40 hours per week; and the facility failed to post the name of the designated person in charge by shift or whenever the Administrator is out of the facility. Findings include, but are not limited to: On 06/11/24 at 4:43 pm and on 06/12/24 at 9:04 am, the Compliance Specialist entered the facility and did not observe a licensed administrator to be onsite. In separate interviews on 06/11/24, Staff 1 (RCC), Staff 5 (CG), Staff 6 (MT), Staff 7 (RCC), Staff 8 (CG), and Staff 9 (CG) stated the following: * At 4:45pm: "There is no administrator for the [memory care]." * The previous administrator stepped down two weeks ago. * If [s/he] doesn't know who's the manager on duty, s/he will go to the med tech. * At 5:00 pm: "[Staff 4] is available via phone [and] not scheduled to be onsite this week." * At 5:30pm: "The Administrator is [Staff 3]." * There was no information provided on who was to fill in when Staff 2 (former MCC Administrator stepped down. *At 5:45 pm, since Staff 2 stepped down, s/he can't say there's been a licensed administrator onsite for 40 hours. In an interview on 06/11/24 at 6:55 pm, Staff 4 (Regional Director of Operations) stated the following: * Staff 3 (Administrator) notified the Department via email on 05/21/24 that s/he would be temporarily absent starting on 05/22/24. * Staff 3 went out on leave on 05/22/24. * Staff 3 had an exception [to be administrator] for ALF and MCC. * S/He was in charge when Staff 3 went out on leave. * Staff 2 stepped down on 05/28/24. * S/He is onsite every week. * Last week, s/he was onsite for a full three days and partially on a fourth day and completed two evaluations for assisted living and one evalution for memory care. When asked what actions were taken with facility staff when Staff 3 stepped down, Staff 4 was unable to provide an answer. On 06/11/24 at 7:35 pm, there were no waivers or exceptions granted or provided that allowed the facility to operate without an administrator. On 06/11/24 at approximately 4:45 pm, it was observed in both the ALF and MCC, the facility's required Designated Person in Charge signage stated "Health Care Coordinator" but lacked the name of the staff member in charge. By 7:35 pm, the signage was updated with a name. On 06/12/24 at 9:05 am, it was observed there was no administrator onsite and the assisted living facility's required Designated Person in Charge signage said "Health Care Coordinator" but lacked the name of the staff member in charge. At 9:16 am, there was no administrator onsite and the MCC facility's required Designated Person in Charge signage was blank. In separate interviews on 06/12/24, Staff 10 (MT), Staff 11 (CG), Staff 12 (CG) and Staff 13 (LPN) stated the following: * S/He identified the RCCs or nurses as the person in charge. * At 9:16 am: "[Staff 2 (former MCC Admin)] stepped down in the end of May." * S/He stated the RCC was in charge when Staff 2 stepped down. * Staff 4 was in the MCC last week when s/he asked about the service plan binder. * S/He did not have Staff 4's contact information. * The previous memory administrator, before Staff 2, left that role in February 2024. * There was no communication to care staff who was filling in as interim Administrator. * Staff 4 spent his/her time last week in Staff 3's office. * Before [Staff 3] went out on leave, s/he sent an email to facility management who would be in charge, but nothing was communicated to the caregivers. * Last week [Staff 4] was onsite three to four days for approximately 10 hour days. In an interview on 06/12/24 at 10:38 am, Witness 1 and Witness 2 stated s/he has not seen any manager in the MCC during their visits. In an interview on 06/12/24 at 11:13 am, Witness 3 and Witness 4 (family members) stated they are in the facility once-to-twice per week. If s/he had concerns, they would go the front desk for help. The MT is usually the staff member in charge unless the "front office door is open, then [s/he would] go to them. But they had a change and don't know who is in charge now." On 06/12/24 at 12:00 pm, Staff 4 was observed to be onsite in the MCC. CS requested Staff 4 provide a written schedule of his/her time onsite. In an email, dated 06/12/24, Staff 4 indicated s/he worked "remote" during the week "05/22- 05/28". In an interview on 06/13/24 at 9:00 am, Witness 5 (ODHS OPA) stated the following: * S/He was notified on or about 05/21/24 via email that Staff 3 will be out and Staff 4 would take over. * S/He was with the understanding that Staff 4 would be onsite 40 hours. * S/He did not have the paperwork required of and for times when a new administrator is stepping into the administrator role for Staff 2. On 06/13/24 at 9:35 am, via telephone, these findings were reviewed with Staff 4. Staff 4 stated his/her team was onsite and s/he was available by phone. Verbal Plan of Correction: The Interim Administrator will be onsite in the community 40-hours until the Executive Director returns. Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the facility failed to provide a full-time administrator to be onsite 40 hours per week; and the facility failed to post the name of the designated person in charge by shift or whenever the Administrator is out of the facility. Findings include, but are not limited to: On 06/11/24 at 4:43 pm and on 06/12/24 at 9:04 am, the Compliance Specialist entered the facility and did not observe a licensed administrator to be onsite. In separate interviews on 06/11/24, Staff 1 (RCC), Staff 5 (CG), Staff 6 (MT), Staff 7 (RCC), Staff 8 (CG), and Staff 9 (CG) stated the following: * At 4:45pm: "There is no administrator for the [memory care]." * The previous administrator stepped down two weeks ago. * If [s/he] doesn't know who's the manager on duty, s/he will go to the med tech. * At 5:00 pm: "[Staff 4] is available via phone [and] not scheduled to be onsite this week." * At 5:30pm: "The Administrator is [Staff 3]." * There was no information provided on who was to fill in when Staff 2 (former MCC Administrator stepped down. *At 5:45 pm, since Staff 2 stepped down, s/he can't say there's been a licensed administrator onsite for 40 hours. In an interview on 06/11/24 at 6:55 pm, Staff 4 (Regional Director of Operations) stated the following: * Staff 3 (Administrator) notified the Department via email on 05/21/24 that s/he would be temporarily absent starting on 05/22/24. * Staff 3 went out on leave on 05/22/24. * Staff 3 had an exception [to be administrator] for ALF and MCC. * S/He was in charge when Staff 3 went out on leave. * Staff 2 stepped down on 05/28/24. * S/He is onsite every week. * Last week, s/he was onsite for a full three days and partially on a fourth day and completed two evaluations for assisted living and one evalution for memory care. When asked what actions were taken with facility staff when Staff 3 stepped down, Staff 4 was unable to provide an answer. On 06/11/24 at 7:35 pm, there were no waivers or exceptions granted or provided that allowed the facility to operate without an administrator. On 06/11/24 at approximately 4:45 pm, it was observed in both the ALF and MCC, the facility's required Designated Person in Charge signage stated "Health Care Coordinator" but lacked the name of the staff member in charge. By 7:35 pm, the signage was updated with a name. On 06/12/24 at 9:05 am, it was observed there was no administrator onsite and the assisted living facility's required Designated Person in Charge signage said "Health Care Coordinator" but lacked the name of the staff member in charge. At 9:16 am, there was no administrator onsite and the MCC facility's required Designated Person in Charge signage was blank. In separate in”

“Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the facility failed to provide a full-time administrator to be onsite 40 hours per week; and the facility failed to post the name of the designated person in charge by shift or whenever the Administrator is out of the facility. Findings include, but are not limited to: On 06/11/24 at 4:43 pm and on 06/12/24 at 9:04 am, the Compliance Specialist entered the facility and did not observe a licensed administrator to be onsite. In separate interviews on 06/11/24, Staff 1 (RCC), Staff 5 (CG), Staff 6 (MT), Staff 7 (RCC), Staff 8 (CG), and Staff 9 (CG) stated the following: * At 4:45pm: "There is no administrator for the [memory care]." * The previous administrator stepped down two weeks ago. * If [s/he] doesn't know who's the manager on duty, s/he will go to the med tech. * At 5:00 pm: "[Staff 4] is available via phone [and] not scheduled to be onsite this week." * At 5:30pm: "The Administrator is [Staff 3]." * There was no information provided on who was to fill in when Staff 2 (former MCC Administrator stepped down. *At 5:45 pm, since Staff 2 stepped down, s/he can't say there's been a licensed administrator onsite for 40 hours. In an interview on 06/11/24 at 6:55 pm, Staff 4 (Regional Director of Operations) stated the following: * Staff 3 (Administrator) notified the Department via email on 05/21/24 that s/he would be temporarily absent starting on 05/22/24. * Staff 3 went out on leave on 05/22/24. * Staff 3 had an exception [to be administrator] for ALF and MCC. * S/He was in charge when Staff 3 went out on leave. * Staff 2 stepped down on 05/28/24. * S/He is onsite every week. * Last week, s/he was onsite for a full three days and partially on a fourth day and completed two evaluations for assisted living and one evalution for memory care. When asked what actions were taken with facility staff when Staff 3 stepped down, Staff 4 was unable to provide an answer. On 06/11/24 at 7:35 pm, there were no waivers or exceptions granted or provided that allowed the facility to operate without an administrator. On 06/11/24 at approximately 4:45 pm, it was observed in both the ALF and MCC, the facility's required Designated Person in Charge signage stated "Health Care Coordinator" but lacked the name of the staff member in charge. By 7:35 pm, the signage was updated with a name. On 06/12/24 at 9:05 am, it was observed there was no administrator onsite and the assisted living facility's required Designated Person in Charge signage said "Health Care Coordinator" but lacked the name of the staff member in charge. At 9:16 am, there was no administrator onsite and the MCC facility's required Designated Person in Charge signage was blank. In separate interviews on 06/12/24, Staff 10 (MT), Staff 11 (CG), Staff 12 (CG) and Staff 13 (LPN) stated the following: * S/He identified the RCCs or nurses as the person in charge. * At 9:16 am: "[Staff 2 (former MCC Admin)] stepped down in the end of May." * S/He stated the RCC was in charge when Staff 2 stepped down. * Staff 4 was in the MCC last week when s/he asked about the service plan binder. * S/He did not have Staff 4's contact information. * The previous memory administrator, before Staff 2, left that role in February 2024. * There was no communication to care staff who was filling in as interim Administrator. * Staff 4 spent his/her time last week in Staff 3's office. * Before [Staff 3] went out on leave, s/he sent an email to facility management who would be in charge, but nothing was communicated to the caregivers. * Last week [Staff 4] was onsite three to four days for approximately 10 hour days. In an interview on 06/12/24 at 10:38 am, Witness 1 and Witness 2 stated s/he has not seen any manager in the MCC during their visits. In an interview on 06/12/24 at 11:13 am, Witness 3 and Witness 4 (family members) stated they are in the facility once-to-twice per week. If s/he had concerns, they would go the front desk for help. The MT is usually the staff member in charge unless the "front office door is open, then [s/he would] go to them. But they had a change and don't know who is in charge now." On 06/12/24 at 12:00 pm, Staff 4 was observed to be onsite in the MCC. CS requested Staff 4 provide a written schedule of his/her time onsite. In an email, dated 06/12/24, Staff 4 indicated s/he worked "remote" during the week "05/22- 05/28". In an interview on 06/13/24 at 9:00 am, Witness 5 (ODHS OPA) stated the following: * S/He was notified on or about 05/21/24 via email that Staff 3 will be out and Staff 4 would take over. * S/He was with the understanding that Staff 4 would be onsite 40 hours. * S/He did not have the paperwork required of and for times when a new administrator is stepping into the administrator role for Staff 2. On 06/13/24 at 9:35 am, via telephone, these findings were reviewed with Staff 4. Staff 4 stated his/her team was onsite and s/he was available by phone. Verbal Plan of Correction: The Interim Administrator will be onsite in the community 40-hours until the Executive Director returns. Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the facility failed to provide a full-time administrator to be onsite 40 hours per week; and the facility failed to post the name of the designated person in charge by shift or whenever the Administrator is out of the facility. Findings include, but are not limited to: On 06/11/24 at 4:43 pm and on 06/12/24 at 9:04 am, the Compliance Specialist entered the facility and did not observe a licensed administrator to be onsite. In separate interviews on 06/11/24, Staff 1 (RCC), Staff 5 (CG), Staff 6 (MT), Staff 7 (RCC), Staff 8 (CG), and Staff 9 (CG) stated the following: * At 4:45pm: "There is no administrator for the [memory care]." * The previous administrator stepped down two weeks ago. * If [s/he] doesn't know who's the manager on duty, s/he will go to the med tech. * At 5:00 pm: "[Staff 4] is available via phone [and] not scheduled to be onsite this week." * At 5:30pm: "The Administrator is [Staff 3]." * There was no information provided on who was to fill in when Staff 2 (former MCC Administrator stepped down. *At 5:45 pm, since Staff 2 stepped down, s/he can't say there's been a licensed administrator onsite for 40 hours. In an interview on 06/11/24 at 6:55 pm, Staff 4 (Regional Director of Operations) stated the following: * Staff 3 (Administrator) notified the Department via email on 05/21/24 that s/he would be temporarily absent starting on 05/22/24. * Staff 3 went out on leave on 05/22/24. * Staff 3 had an exception [to be administrator] for ALF and MCC. * S/He was in charge when Staff 3 went out on leave. * Staff 2 stepped down on 05/28/24. * S/He is onsite every week. * Last week, s/he was onsite for a full three days and partially on a fourth day and completed two evaluations for assisted living and one evalution for memory care. When asked what actions were taken with facility staff when Staff 3 stepped down, Staff 4 was unable to provide an answer. On 06/11/24 at 7:35 pm, there were no waivers or exceptions granted or provided that allowed the facility to operate without an administrator. On 06/11/24 at approximately 4:45 pm, it was observed in both the ALF and MCC, the facility's required Designated Person in Charge signage stated "Health Care Coordinator" but lacked the name of the staff member in charge. By 7:35 pm, the signage was updated with a name. On 06/12/24 at 9:05 am, it was observed there was no administrator onsite and the assisted living facility's required Designated Person in Charge signage said "Health Care Coordinator" but lacked the name of the staff member in charge. At 9:16 am, there was no administrator onsite and the MCC facility's required Designated Person in Charge signage was blank. In separate in”

“Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the facility failed to fully implement and update an acuity based staffing tool. Findings include, but are not limited to: A. In an interview on 06/12/24, Staff 4 (Regional Director of Operations) stated the facility used the state's ODHS ABST and the facility is home to 17 residents. Review of the facility's posted staffing plan indicated the following: * Day shift (6am - 2pm): one medication technician (MT), three CG, half (.5) Activity Worker, and half (.5) "other workers"; * Swing shift (2pm - 10pm): one MT, two and quarter (2.25) CG, half (.5) Activity Worker, and half (.5) "other workers"; and * Night shift (10pm - 6am): one MT and one CG. B.  A review of the facility's ABST with Staff 4, indicated the following: * There were 22 ADLs listed. * A staffing plan did generate a 24-hour staffing plan. * A total of ten residents' profiles had not been updated/reviewed in the last quarter as evident by the last edit date of 02/06/24,  02/07/24, and 03/01/24. A review of Residents 1, 2, and 3's records and ABST profiles indicated the following: * Resident 1's service plan, dated 05/08/24 and updated 06/11/24, indicated in the area of "transferring" was updated on 06/07/24, directed staff s/he required "one-person assistance with all transfers as tolerated" and "may occasional 2-person assistance especially while dressing or toileting". * A progress note entered on 06/11/24 as a part of monitoring Resident 1 for return from hospital on 06/07/24 indicated "Resident is usually requiring 2-person assist, unable to ambulate on [his/her] own..... unable to follow simple commands." * Resident 1's profile was lasted edited on 05/13/24 and lacked any time dedicated for transfers and the time needed to additional-second staff member. * Resident 2's service plan, dated 05/02/24, indicated s/he was at risk for falls, elopement, required reminders for eating, and experienced behaviors. In the area of behaviors, staff were directed to "anticipate behaviors... redirect with an activity, snack/fluids, or redirect to a quiet space for one-on-one." * Resident 2's profile was lasted edited on 03/18/24 and lacked any time dedicated for safety checks and fall preventions, assistance with leisure activities, and supervising/cueing while eating. * Resident 3's service plan, dated 05/06/24 and updated 06/10/24, indicated the area of "eating" was revised on 06/11/24. S/He required "cueing/encouragement w/meals....Staff to provide hands on assistance with feeding..." * An Interim Service Plan and progress note, dated 06/08/24 and entered at 2:09 pm, indicated "staff to provide cueing/encouragement... including hands on assistance with meals." * Resident 3's profile was last edited on 02/06/24, and lacked any increase in the allotted care time in the area of eating to account for the time required to provide hands-on feeding assistance. A review of the facility's activity calendar, dated June 2024, indicated on 06/12/24, six different activities were scheduled including exercise time, walking club, bingo, daily chronicles. On 06/12/24, the Compliance Specialist observed the following: * No scheduled communal or individual-resident focused activities occurred. * There were two CGs and one MT on duty. * At 11:43 am, while Staff 11 (CG) provided assistance in the dining room and Staff 12 (CG) was in a resident's apartment to provide toileting assistance, Resident 4 was observed walking while hunched over his/her walker. Staff 10 (MT) intervened and called twice via radio for assistance, "before [the resident] falls." The resident then fell to his/her knees prompting Staff 10 to announce: "too late." Staff 11 responded to the request, resulting in the dining room meal service to be halted and the dining room unsupervised. * At 11:50 am, Resident 2 exited the dining room after minimal consumption of soup, soda, and fruit punch. Resident 2 proceeded to pace in his/her wheelchair in common area living room and hallway, crying, checking exit door handles, yelling at other residents. At 12:01 pm, Staff 10 addressed Resident 2's behavior by reminding him/her not to talk to other residents in that way. At which time, Staff 10 moved Resident 2 to the end of the hall away from all persons. At 12:17 pm, Staff 10 is looking for Resident 2 but wasn't down the hall where Staff 10 last saw him/her or in any apartments. CS observed Staff 10 locate Resident 2 banging on the exterior courtyard gate. * Residents 1, 2, and 3 were dressed in clean clothing appropriate for time of day and season and slip-resistant socks; were free of unpleasant odors, and their hair was groomed. C. A review of staff schedule, dated 06/01/24 through 06/30/24, timecards, dated 06/01/24, 06/04/24 through 06/08/24, indicated on a total of six different days, or 7 different shifts, in which the facility did not meet their staffing plan. D. In separate interviews on 06/11/24 and 06/12/24, Staff 5 (CG), 6 (MT), 8 (CG), 9 (CG), 10, 11, and 12 stated the following: * Showers were provided for these days and were provided unless the resident refused. * S/He had no concerns with their ability to meet residents needs when staffed with three caregivers. * S/He had not received any reports of needs being missed or complaints related to quality of care. In an interview on 06/12/24 at 11:13 am, Witness 3 and 4 stated they rated their satisfaction with the quality of care at the facility as "very good". On 06/12/24, these findings were reviewed with and acknowledged by Staff 4. The facility failed to fully implement and update an acuity based staffing tool. Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the facility failed to fully implement and update an acuity based staffing tool. Findings include, but are not limited to: A. In an interview on 06/12/24, Staff 4 (Regional Director of Operations) stated the facility used the state's ODHS ABST and the facility is home to 17 residents. Review of the facility's posted staffing plan indicated the following: * Day shift (6am - 2pm): one medication technician (MT), three CG, half (.5) Activity Worker, and half (.5) "other workers"; * Swing shift (2pm - 10pm): one MT, two and quarter (2.25) CG, half (.5) Activity Worker, and half (.5) "other workers"; and * Night shift (10pm - 6am): one MT and one CG. B.  A review of the facility's ABST with Staff 4, indicated the following: * There were 22 ADLs listed. * A staffing plan did generate a 24-hour staffing plan. * A total of ten residents' profiles had not been updated/reviewed in the last quarter as evident by the last edit date of 02/06/24,  02/07/24, and 03/01/24. A review of Residents 1, 2, and 3's records and ABST profiles indicated the following: * Resident 1's service plan, dated 05/08/24 and updated 06/11/24, indicated in the area of "transferring" was updated on 06/07/24, directed staff s/he required "one-person assistance with all transfers as tolerated" and "may occasional 2-person assistance especially while dressing or toileting". * A progress note entered on 06/11/24 as a part of monitoring Resident 1 for return from hospital on 06/07/24 indicated "Resident is usually requiring 2-person assist, unable to ambulate on [his/her] own..... unable to follow simple commands." * Resident 1's profile was lasted edited on 05/13/24 and lacked any time dedicated for transfers and the time needed to additional-second staff member. * Resident 2's service plan, dated 05/02/24, indicated s/he was at risk for falls, elopement, required reminders for eating, and experienced behaviors. In the area of behaviors, staff were directed to "anticipate behaviors... redirect with an activity, snack/fluids, or redirect to a quiet space for one-on-one." * Resident 2's profile was lasted edited on 03/18/24 and lacked any time dedicated ”

“Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the faciltiy failed to individually identify resident's rooms to assist residents in recognizing their room for 1 of 1 sampled resident (#2). Findings include, but not limited to: A review of the facility's resident roster, dated 06/11/2024, indicated what apartment belonged to Resident 2. Throughout the site visit, the Compliance Specialist observed Resident 2's apartment lacked any identifiable information that would assist Resident 2 with recognizing his/her apartment. In an interview on 06/12/24 at 2:00 pm, Staff 4 (Regional Director of Operations) stated residents' names should be on their memory boxes, but sometimes residents take them down. On 06/12/24, these findings were reviewed with and acknowledged by Staff 4. No further information provided. The faciltiy failed to individually identify resident's rooms to assist residents in recognizing their room. Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the faciltiy failed to individually identify resident's rooms to assist residents in recognizing their room for 1 of 1 sampled resident (#2). Findings include, but not limited to: A review of the facility's resident roster, dated 06/11/2024, indicated what apartment belonged to Resident 2. Throughout the site visit, the Compliance Specialist observed Resident 2's apartment lacked any identifiable information that would assist Resident 2 with recognizing his/her apartment. In an interview on 06/12/24 at 2:00 pm, Staff 4 (Regional Director of Operations) stated residents' names should be on their memory boxes, but sometimes residents take them down. On 06/12/24, these findings were reviewed with and acknowledged by Staff 4. No further information provided. The faciltiy failed to individually identify resident's rooms to assist residents in recognizing their room.”

“The findings of the kitchen inspection, conducted 04/30/24, 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 kitchen inspection, conducted 04/30/24, 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, interview and record review, conducted during a site visit on 02/26/24 and 02/28/24, it was confirmed the  facility failed to ensure each residential care and assisted living facility must be licensed, maintained, and operated as a separate and distinct facility. Findings include, but are not limited to: During an interview on 02/26/24, Staff 4 (MT) stated the Memory Care community had to call staff over from the Assisted Living Community to assist residents with behaviors two times per week. During an interview on 02/26/24, Staff 6 (MT/CG) stated on night shift of 02/17/24, there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community. During an interview on 02/28/24, Staff 10 (CG) stated on night shift of 02/23/24 there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community. Time cards for the facility were reviewed for night shift on 02/17/24 and 02/23/24 which confirmed there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community. Upon entrance to the facility at 12:50 am on 12/28/24, two ALF staff members were observed in the memory care. During an interview on 02/28/24, Staff 6 (ALF MT) stated ALF staff are pulled to help in the MC at least a couple times/week. During an interview by phone on 02/28/24, Staff 8 (Executive Director) stated she was not aware staff were being shared between facilities. The facility failed to ensure each residential care and assisted living facility must be licensed, maintained, and operated as a separate and distinct facility. The findings were reviewed with and acknowledged by Staff 8 by phone on 03/01/24. Verbal plan of correction: Administrator will work to get exception to float an additional staff between facilties. Counseling with RCCs to not leave shifts open so that MTs aren ' t working the whole facility on night to be provided by 03/01/24. Administrator will educate staff on communicating their needs and not sharing staff between two facilities. Based on observation, interview and record review, conducted during a site visit on 02/26/24 and 02/28/24, it was confirmed the  facility failed to ensure each residential care and assisted living facility must be licensed, maintained, and operated as a separate and distinct facility. Findings include, but are not limited to: During an interview on 02/26/24, Staff 4 (MT) stated the Memory Care community had to call staff over from the Assisted Living Community to assist residents with behaviors two times per week. During an interview on 02/26/24, Staff 6 (MT/CG) stated on night shift of 02/17/24, there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community. During an interview on 02/28/24, Staff 10 (CG) stated on night shift of 02/23/24 there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community. Time cards for the facility were reviewed for night shift on 02/17/24 and 02/23/24 which confirmed there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community. Upon entrance to the facility at 12:50 am on 12/28/24, two ALF staff members were observed in the memory care. During an interview on 02/28/24, Staff 6 (ALF MT) stated ALF staff are pulled to help in the MC at least a couple times/week. During an interview by phone on 02/28/24, Staff 8 (Executive Director) stated she was not aware staff were being shared between facilities. The facility failed to ensure each residential care and assisted living facility must be licensed, maintained, and operated as a separate and distinct facility. The findings were reviewed with and acknowledged by Staff 8 by phone on 03/01/24. Verbal plan of correction: Administrator will work to get exception to float an additional staff between facilties. Counseling with RCCs to not leave shifts open so that MTs aren ' t working the whole facility on night to be provided by 03/01/24. Administrator will educate staff on communicating their needs and not sharing staff between two facilities.”

“Based on observation, interview and record review, conducted during a site visit on 02/26/24 and 02/28/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: A review of the facility's posted staffing plan indicated that one MT and one CG were to be scheduled on night shift. 1 CG and 1 MT were observed working on night shift on 02/26/24 and 02/28/24. During an interview on 02/26/24, Staff 4 (MT) stated the Memory Care Community (MCC) had to call staff over from the Assisted Living Community (ALF) to assist residents with behaviors in the MCC two times per week. Staff 4 further stated that residents have pulled their fire alarms multiple times, which unlocked three exit doors and the gate from their courtyard. Staff 4 stated that when that happened on noc shift, they were not able to monitor the exits with only two scheduled staff. Records were requested for each time the fire alarm had been activated in the previous six months, but were not provided by 03/06/24. During an interview on 02/26/24, Staff 6 (MT/CG) stated on night shift of 02/17/24, there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community. During an interview on 02/28/24, Staff 10 (CG) stated on night shift of 02/23/24 there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community. Time cards for the facility were reviewed for night shift on 02/17/24 and 02/23/24 which confirmed there was only one MT who was responsible for passing medications for both the ALF and MCC. Upon entrance to the facility at 12:50 am on 12/28/24, two ALF staff members were observed in the MCC. During an interview on 02/28/24, Staff 6 (ALF MT) stated ALF staff awere pulled to help in the MCC at least a couple times per week. The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. The findings were reviewed with and acknowledged by Staff 8 (Executive Director) by phone on 03/01/24. Verbal plan of correction: Executive Director is working with her supervisor to have a night shift float and will request an exception from Operations and Policy Analyst for that. Facility will hire a float staff for that once exception is in place. In the mean time, will  have RCC or other staff cover an additional night shift. Based on observation, interview and record review, conducted during a site visit on 02/26/24 and 02/28/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: A review of the facility's posted staffing plan indicated that one MT and one CG were to be scheduled on night shift. 1 CG and 1 MT were observed working on night shift on 02/26/24 and 02/28/24. During an interview on 02/26/24, Staff 4 (MT) stated the Memory Care Community (MCC) had to call staff over from the Assisted Living Community (ALF) to assist residents with behaviors in the MCC two times per week. Staff 4 further stated that residents have pulled their fire alarms multiple times, which unlocked three exit doors and the gate from their courtyard. Staff 4 stated that when that happened on noc shift, they were not able to monitor the exits with only two scheduled staff. Records were requested for each time the fire alarm had been activated in the previous six months, but were not provided by 03/06/24. During an interview on 02/26/24, Staff 6 (MT/CG) stated on night shift of 02/17/24, there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community. During an interview on 02/28/24, Staff 10 (CG) stated on night shift of 02/23/24 there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community. Time cards for the facility were reviewed for night shift on 02/17/24 and 02/23/24 which confirmed there was only one MT who was responsible for passing medications for both the ALF and MCC. Upon entrance to the facility at 12:50 am on 12/28/24, two ALF staff members were observed in the MCC. During an interview on 02/28/24, Staff 6 (ALF MT) stated ALF staff awere pulled to help in the MCC at least a couple times per week. The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. The findings were reviewed with and acknowledged by Staff 8 (Executive Director) by phone on 03/01/24. Verbal plan of correction: Executive Director is working with her supervisor to have a night shift float and will request an exception from Operations and Policy Analyst for that. Facility will hire a float staff for that once exception is in place. In the mean time, will  have RCC or other staff cover an additional night shift.”

“Based on observation, interview and record review, conducted during a site visit on 02/26/28/24 and 02/28/24, it was confirmed facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing for 1 of 1 sampled staff (#5). Findings include, but are not limited to: Staff 5 was observed working as a CG in the Memory Care Community (MCC) on 02/26/24. During an interview on 02/26/24, Staff 5 stated that s/he worked two shifts as a MT in the ALF and two shifts as a CG in the MCC per week since November 2023. S/he further stated that on night shift of 02/17/24, s/he had worked as the only MT for both the ALF and the MCC and had not been trained to pass medications in the MCC. Time cards for 02/17/24 confirmed Staff 5 had worked as the only MT for both the ALF and the MC. There was no documented evidence that Staff 5 had received training for the Memory Care. The facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing. The findings were reviewed with and acknowledged by Staff 8 (Executive Director) by phone on 03/01/24. Verbal plan of correction: Train staff in question. Audit all training documents to ensure that staff have received training and its documented. Audit will be done by Wednesday and training updated within 30 days. Based on observation, interview and record review, conducted during a site visit on 02/26/28/24 and 02/28/24, it was confirmed facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing for 1 of 1 sampled staff (#5). Findings include, but are not limited to: Staff 5 was observed working as a CG in the Memory Care Community (MCC) on 02/26/24. During an interview on 02/26/24, Staff 5 stated that s/he worked two shifts as a MT in the ALF and two shifts as a CG in the MCC per week since November 2023. S/he further stated that on night shift of 02/17/24, s/he had worked as the only MT for both the ALF and the MCC and had not been trained to pass medications in the MCC. Time cards for 02/17/24 confirmed Staff 5 had worked as the only MT for both the ALF and the MC. There was no documented evidence that Staff 5 had received training for the Memory Care. The facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing. The findings were reviewed with and acknowledged by Staff 8 (Executive Director) by phone on 03/01/24. Verbal plan of correction: Train staff in question. Audit all training documents to ensure that staff have received training and its documented. Audit will be done by Wednesday and training updated within 30 days.”