Sweetbriar Villa.

“Based on observations and interviews, it was determined the facility failed to maintain the kitchen in a sanitary manner and serve food at palatable temperatures and appropriate textures in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the kitchen on 06/05/25 at 10:45 am through 1:00pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, around or underneath the following: * Kitchen drains * Industrial mixer and slicer * Industrial can opener * Metal large can rack * Metal shelf above cooking area * Interior of stainless-steel drawers * Juice machine * Lids of bulk bins * Popcorn maker * Stainless-steel shelving b. The following areas were in need of repair: * Light switch cover cracked * Area around floor electrical outlet in Dining room with gap in caulking. c. Both surface sanitizer buckets were found not a proper concentration (Parts Per Million) for effective sanitizing. Facility’s test strips did not turn any color indicating zero active sanitizing chemical available in the red buckets meant for sanitizing surfaces. Facility made fresh buckets and were found at appropriate PPM for sanitizer concentration. d. Multiple food items were found not dated when opened. e. Multiple containers of bulk dry goods had cups or scoops stored in them with the handles or hand contact surfaces touching the food product potentially contaminating the items. f. The small memory care refrigerator was noted at 48 degrees. The facility was not able to demonstrate an effective process for monitoring the mini fridge temperatures for cold food storage. Multiple resident food items were observed stored in that refrigerator. g. Some items in reach in freezers were observed not fully covered/protected from potential contamination. h. Two residents on minced and moist diet textures were served minced meat but with bbq sauce poured on top. For this diet type mixed textures are not permitted and must be thoroughly mixed into the product yielding one texture. The temperature of the BBQ pork was also noted to be at 118 degrees Fahrenheit and was about to be served to the residents at that lower temperature. Surveyor interviewed and instructed that food must be hot held and leave the kitchen at 135 degrees or hotter. Staff 2 (Dining Services Director) acknowledged the food was not hot enough and was going to be served at unpalatable temperatures. Food was reheated to a higher and more palatable temperature before served to residents. i. Caregiving staff in memory care unit that were assisting residents with their meals did not have aprons/protective barriers on to prevent possible contamination from their clothing during meals. j. Industrial slicer was observed uncovered and not protected from potential contamination when stored/not in use. At 12:45 pm, the surveyor reviewed above identified areas with both Staff 1 (Executive Director) and Staff 2 who acknowledged the of areas in need of correction.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure the plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to: C240. Refer to C 240. OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:”

“Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. Refer to C240. OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to: C240. Refer to C 240. OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:”

“Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of Resident 1's August 2024 MAR and progress notes, incident report dated 08/14/24, and Interim Service Plan dated 08/15/24 indicated the following: · Novolog 100-U/ML PEN 3ML to be injected 11 units before breakfast and 10 units before lunch and dinner for diabetes. · Tresiba 100-U/ML PEN 3ML to be injected 18 units every day at 8 pm for diabetes. · Resident 2 did not receive his/her Novolog 100-U/ML PEN 3ML on 08/14/25 at 7:30 am and 11:30 am and was administered Tresiba 100-U/ML PEN 3ML in error before breakfast and lunch. In an interview, Staff 2 (Wellness Nurse) stated the incident had occurred. The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 03/25/25. The facility's failure to carry out medication and treatment orders as prescribed was substantiated. Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#2). Findings include, but are not limited to: A review of Resident 2's November 2023 MAR and progress notes, incident report dated 11/09/23, and Interim Service Plan dated 11/10/23 indicated the following: · Tramadol 50mg Tab to be given twice daily at 8 am and 2 pm. · Resident 2 did not receive his/her scheduled doses of Tramadol on 11/09/23 at 8 am and 2 pm. In an interview, Staff 2 (Wellness Nurse) stated the incident had occurred. The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 03/25/25. The facility's failure to carry out medication and treatment orders as prescribed was substantiated. Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of Resident 1's August 2024 MAR and progress notes, incident report dated 08/14/24, and Interim Service Plan dated 08/15/24 indicated the following: · Novolog 100-U/ML PEN 3ML to be injected 11 units before breakfast and 10 units before lunch and dinner for diabetes. · Tresiba 100-U/ML PEN 3ML to be injected 18 units every day at 8 pm for diabetes. · Resident 2 did not receive his/her Novolog 100-U/ML PEN 3ML on 08/14/25 at 7:30 am and 11:30 am and was administered Tresiba 100-U/ML PEN 3ML in error before breakfast and lunch. In an interview, Staff 2 (Wellness Nurse) stated the incident had occurred. The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 03/25/25. The facility's failure to carry out medication and treatment orders as prescribed was substantiated. Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#2). Findings include, but are not limited to: A review of Resident 2's November 2023 MAR and progress notes, incident report dated 11/09/23, and Interim Service Plan dated 11/10/23 indicated the following: · Tramadol 50mg Tab to be given twice daily at 8 am and 2 pm. · Resident 2 did not receive his/her scheduled doses of Tramadol on 11/09/23 at 8 am and 2 pm. In an interview, Staff 2 (Wellness Nurse) stated the incident had occurred. The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 03/25/25. The facility's failure to carry out medication and treatment orders as prescribed was substantiated.”

“Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated that not all 33 residents had completed ABST evaluations, and the residents had not been updated at least quarterly. A review of the ABST indicated the following: ·       Day shift: Assisted Living (AL) 15.25 and Memory Care (MC) 5.37 staff required. ·       Swing shift: AL 12.73 and MC 4.95 staff required. ·       Night shift: AL 6.02 and MC 2.4 staff required. A review of the posted staffing plan and staffing schedules for 03/19/25 through 03/25/25 indicated the following: ·       Day shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required. ·       Swing shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required. ·       Night shift: AL one CG and 0.50 MT; MC one CG and 0.50 MT required. ·       The posted staffing plan did not account for fire and life safety on the night shift considering multiple transfer care, segregated areas, or behavioral needs. ·      The facility had five residents (two AL and three MC) requiring two-person transfers and was not consistently scheduling two care staff in each segregated area on the night shift. In an interview on 03/26/25, Staff 1 (Executive Director) stated the following: ·       Staff 1 did not know they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance. ·       Staff 1 included the shared med tech as the second staff member available for two-person transfers on the night shift. Findings were reviewed with and acknowledged by Staff 1 during a phone call on 03/26/25. The facility's failure to have a fully implemented and updated ABST was substantiated. Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated that not all 33 residents had completed ABST evaluations, and the residents had not been updated at least quarterly. A review of the ABST indicated the following: ·       Day shift: Assisted Living (AL) 15.25 and Memory Care (MC) 5.37 staff required. ·       Swing shift: AL 12.73 and MC 4.95 staff required. ·       Night shift: AL 6.02 and MC 2.4 staff required. A review of the posted staffing plan and staffing schedules for 03/19/25 through 03/25/25 indicated the following: ·       Day shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required. ·       Swing shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required. ·       Night shift: AL one CG and 0.50 MT; MC one CG and 0.50 MT required. ·       The posted staffing plan did not account for fire and life safety on the night shift considering multiple transfer care, segregated areas, or behavioral needs. ·      The facility had five residents (two AL and three MC) requiring two-person transfers and was not consistently scheduling two care staff in each segregated area on the night shift. In an interview on 03/26/25, Staff 1 (Executive Director) stated the following: ·       Staff 1 did not know they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance. ·       Staff 1 included the shared med tech as the second staff member available for two-person transfers on the night shift. Findings were reviewed with and acknowledged by Staff 1 during a phone call on 03/26/25. The facility's failure to have a fully implemented and updated ABST was substantiated.”

“Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated that not all 33 residents had completed ABST evaluations, and the residents had not been updated at least quarterly. A review of the ABST indicated the following: ·       Day shift: Assisted Living (AL) 15.25 and Memory Care (MC) 5.37 staff required. ·       Swing shift: AL 12.73 and MC 4.95 staff required. ·       Night shift: AL 6.02 and MC 2.4 staff required. A review of the posted staffing plan and staffing schedules for 03/19/25 through 03/25/25 indicated the following: ·       Day shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required. ·       Swing shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required. ·       Night shift: AL one CG and 0.50 MT; MC one CG and 0.50 MT required. ·       The posted staffing plan did not account for fire and life safety on the night shift considering multiple transfer care, segregated areas, or behavioral needs. ·      The facility had five residents (two AL and three MC) requiring two-person transfers and was not consistently scheduling two care staff in each segregated area on the night shift. In an interview on 03/26/25, Staff 1 (Executive Director) stated the following: ·       Staff 1 did not know they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance. ·       Staff 1 included the shared med tech as the second staff member available for two-person transfers on the night shift. Findings were reviewed with and acknowledged by Staff 1 during a phone call on 03/26/25. The facility's failure to have a fully implemented and updated ABST was substantiated. Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated that not all 33 residents had completed ABST evaluations, and the residents had not been updated at least quarterly. A review of the ABST indicated the following: ·       Day shift: Assisted Living (AL) 15.25 and Memory Care (MC) 5.37 staff required. ·       Swing shift: AL 12.73 and MC 4.95 staff required. ·       Night shift: AL 6.02 and MC 2.4 staff required. A review of the posted staffing plan and staffing schedules for 03/19/25 through 03/25/25 indicated the following: ·       Day shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required. ·       Swing shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required. ·       Night shift: AL one CG and 0.50 MT; MC one CG and 0.50 MT required. ·       The posted staffing plan did not account for fire and life safety on the night shift considering multiple transfer care, segregated areas, or behavioral needs. ·      The facility had five residents (two AL and three MC) requiring two-person transfers and was not consistently scheduling two care staff in each segregated area on the night shift. In an interview on 03/26/25, Staff 1 (Executive Director) stated the following: ·       Staff 1 did not know they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance. ·       Staff 1 included the shared med tech as the second staff member available for two-person transfers on the night shift. Findings were reviewed with and acknowledged by Staff 1 during a phone call on 03/26/25. The facility's failure to have a fully implemented and updated ABST was substantiated.”

“Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated that not all 33 residents had completed ABST evaluations, and the residents had not been updated at least quarterly. A review of the ABST indicated the following: ·       Day shift: Assisted Living (AL) 15.25 and Memory Care (MC) 5.37 staff required. ·       Swing shift: AL 12.73 and MC 4.95 staff required. ·       Night shift: AL 6.02 and MC 2.4 staff required. A review of the posted staffing plan and staffing schedules for 03/19/25 through 03/25/25 indicated the following: ·       Day shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required. ·       Swing shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required. ·       Night shift: AL one CG and 0.50 MT; MC one CG and 0.50 MT required. ·       The posted staffing plan did not account for fire and life safety on the night shift considering multiple transfer care, segregated areas, or behavioral needs. ·      The facility had five residents (two AL and three MC) requiring two-person transfers and was not consistently scheduling two care staff in each segregated area on the night shift. In an interview on 03/26/25, Staff 1 (Executive Director) stated the following: ·       Staff 1 did not know they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance. ·       Staff 1 included the shared med tech as the second staff member available for two-person transfers on the night shift. Findings were reviewed with and acknowledged by Staff 1 during a phone call on 03/26/25. The facility's failure to have a fully implemented and updated ABST was substantiated. Based on interview and record review, conducted during a site visit on 03/25/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated that not all 33 residents had completed ABST evaluations, and the residents had not been updated at least quarterly. A review of the ABST indicated the following: ·       Day shift: Assisted Living (AL) 15.25 and Memory Care (MC) 5.37 staff required. ·       Swing shift: AL 12.73 and MC 4.95 staff required. ·       Night shift: AL 6.02 and MC 2.4 staff required. A review of the posted staffing plan and staffing schedules for 03/19/25 through 03/25/25 indicated the following: ·       Day shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required. ·       Swing shift: AL two CGs and 0.50 MT; MC two CGs and 0.50 MT required. ·       Night shift: AL one CG and 0.50 MT; MC one CG and 0.50 MT required. ·       The posted staffing plan did not account for fire and life safety on the night shift considering multiple transfer care, segregated areas, or behavioral needs. ·      The facility had five residents (two AL and three MC) requiring two-person transfers and was not consistently scheduling two care staff in each segregated area on the night shift. In an interview on 03/26/25, Staff 1 (Executive Director) stated the following: ·       Staff 1 did not know they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance. ·       Staff 1 included the shared med tech as the second staff member available for two-person transfers on the night shift. Findings were reviewed with and acknowledged by Staff 1 during a phone call on 03/26/25. The facility's failure to have a fully implemented and updated ABST was substantiated.”

“The findings of the kitchen inspection, conducted 04/11/24 - 04/12/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the kitchen inspection, conducted 04/11/24 - 04/12/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the re-visit to the kitchen inspection of 04/12/24, conducted 07/03/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. 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. The findings of the re-visit to the kitchen inspection of 04/12/24, conducted 07/03/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. 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. The findings of the second revisit to the kitchen inspection of 04/12/24, conducted 09/16/24, 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 second revisit to the kitchen inspection of 04/12/24, conducted 09/16/24, 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 observations and interviews, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the kitchen on 04/11/24 at 10:30 am through 12:30 pm, and on 04/12/24 from 11:30 am through 2:00 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine; * Kitchen drains; * Electrical outlets and light switches; * Ceiling fire vents and light fixtures; * Wall behind prep area where knives were stored; * Stove top, oven doors, interior, and exterior; * Industrial mixer and slicer; * Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under and between equipment; * Rack shelving in dry good storage; * Under and behind shelving in dry good storage; * Exterior and interior of reach in refrigerators and freezers; * Interior of food cart; and * Cabinet under sink in memory care kitchenette. b. The following areas were in need of repair: * Section of caulking by dish machine with black debris build up; * Small refrigerator in Memory Care unit with frost build up; * Cabinet under sink in Memory Care unit with damage to wall (hole in concrete) and: * Section of base board missing in Memory Care kitchenette. c. Surface sanitizer strips were not stored properly and were visibly damaged. d. Multiple food items were found not dated when opened. Some items were found past seven days and should have been discarded. Whole shell eggs were found stored above RTE (ready to eat) food items causing potential for cross contamination. e. Multiple containers of bulk dry goods had cups or scoops stored in them. f. Large bucket of used/dirty cooking oil found stored without a cover. g. Some items in refrigerator weren't covered/protected from potential contamination. h. Multiple staff observed coming in kitchen area without washing hands or performing hand hygiene and without hair restrained as required. Two kitchen employees were observed preparing food/handling clean equipment without facial hair restrained. i. Caregiving staff assisting residents with their meals did not have aprons on to prevent possible contamination from their clothing during meals. j. Kitchen staff returned from a break without washing hands. They were also observed to drink from a canned beverage and not wash hands. Cook was observed to wash hands in a prep sink and dry hands on a cloth towel. k. Staff member assisting in dining room during meal service was observed to handle their phone then assist residents with beverages and meals without performing hand hygiene. The hand sanitizer dispenser in the dining room was observed not operational during the survey process. One 04/12/24 At 1:15 pm, the surveyor reviewed with Staff 2 (Dining Service Director) areas in need of cleaning, repair and attention. S/he acknowledged areas. At approximately 1:45 pm, Staff 1 (Executive Director) was informed and acknowledged the of areas in need of correction. Based on observations and interviews, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the kitchen on 04/11/24 at 10:30 am through 12:30 pm, and on 04/12/24 from 11:30 am through 2:00 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine; * Kitchen drains; * Electrical outlets and light switches; * Ceiling fire vents and light fixtures; * Wall behind prep area where knives were stored; * Stove top, oven doors, interior, and exterior; * Industrial mixer and slicer; * Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under and between equipment; * Rack shelving in dry good storage; * Under and behind shelving in dry good storage; * Exterior and interior of reach in refrigerators and freezers; * Interior of food cart; and * Cabinet under sink in memory care kitchenette. b. The following areas were in need of repair: * Section of caulking by dish machine with black debris build up; * Small refrigerator in Memory Care unit with frost build up; * Cabinet under sink in Memory Care unit with damage to wall (hole in concrete) and: * Section of base board missing in Memory Care kitchenette. c. Surface sanitizer strips were not stored properly and were visibly damaged. d. Multiple food items were found not dated when opened. Some items were found past seven days and should have been discarded. Whole shell eggs were found stored above RTE (ready to eat) food items causing potential for cross contamination. e. Multiple containers of bulk dry goods had cups or scoops stored in them. f. Large bucket of used/dirty cooking oil found stored without a cover. g. Some items in refrigerator weren't covered/protected from potential contamination. h. Multiple staff observed coming in kitchen area without washing hands or performing hand hygiene and without hair restrained as required. Two kitchen employees were observed preparing food/handling clean equipment without facial hair restrained. i. Caregiving staff assisting residents with their meals did not have aprons on to prevent possible contamination from their clothing during meals. j. Kitchen staff returned from a break without washing hands. They were also observed to drink from a canned beverage and not wash hands. Cook was observed to wash hands in a prep sink and dry hands on a cloth towel. k. Staff member assisting in dining room during meal service was observed to handle their phone then assist residents with beverages and meals without performing hand hygiene. The hand sanitizer dispenser in the dining room was observed not operational during the survey process. One 04/12/24 At 1:15 pm, the surveyor reviewed with Staff 2 (Dining Service Director) areas in need of cleaning, repair and attention. S/he acknowledged areas. At approximately 1:45 pm, Staff 1 (Executive Director) was informed and acknowledged the of areas in need of correction.”

“Based on interview, observation, and review of records, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240. Based on interview, observation, and review of records, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240. Refer to C240 Refer to C240 There are no detail notes for this visit.”

“Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. Refer to C240. Refer to C240. 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 240. 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 240. Refer to C240 Refer to C240 There are no detail notes for this visit.”

“The findings of the on-site investigation, conducted on 09/22/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day The findings of the on-site investigation, conducted on 09/22/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day”

“Based on interview and record review, conducted during a site visit on 09/22/23, it was determined the facility failed to provide a safe and home-like environment  for 1 of 1 sampled resident (#4) whose records were reviewed. Findings include, but are not limited to: In separate interviews on 09/22/23, Staff 1 (Life Enrichment Director) and Staff 2 (Wellness Director) had both stated that Resident 4 was moved to the "assisted living" from the Memory Care (MC) due to another resident in the MC targeting him/her. S/he also stated Resident 4 was moved back to the MC after the other resident had passed away. Staff 2 stated they were unaware of how long the resident was in the "AL" and to his/her knowledge, staffing was not increased to during that time. In a phone interview on 09/26/23, Staff 3 (ED) stated s/he was unaware if there was an assessment done or a new service plan put into place when the resident moved into the "AL".  S/he stated they would need to look through the documents. There was no evidence to indicate an assessment or service plan was completed when Resident 4 moved into the AL from the MC in August 2022. A review of progress notes dated August 2022 through April 2023, indicated Resident 4 was moved from the MC to AL on 08/30/22 and was moved back to the MC on 04/05/23. A progress note dated 08/30/22 at 12:44pm indicated that the facility had spoke to Resident 4's family member about trialing a move to the AL side to separate the 2 residents and s/he liked the idea. A progress note dated 02/15/23 at 3:30pm indicated a quarterly assessment was completed on 02/14/23 and that Resident 4 had very poor short-term memory and required frequent re-direction. CS reviewed Resident 4's service plans dated 10/12/21 and 03/03/23 which indicated the following: · "Resident not oriented to place or time" · "Does not have the ability to use or manage a key" · "Very poor short-term memory requiring frequent re-direction" · "Often exit seeks which can cause others in MC to exit seek as well" · "Wanders up and down hallways and will frequently ask where room is, for staff to show where the bathroom is, or when the next meal is" · Both service plans indicated Resident 4's MC room number , even during the time s/he was living in the AL. These findings were shared with Staff 2 and Staff 3 via email on 09/29/23. It was determined the facility failed to provide a safe and home-like environment. Verbal plan of correction: No plan of correction was provided Based on interview and record review, conducted during a site visit on 09/22/23, it was determined the facility failed to provide a safe and home-like environment  for 1 of 1 sampled resident (#4) whose records were reviewed. Findings include, but are not limited to: In separate interviews on 09/22/23, Staff 1 (Life Enrichment Director) and Staff 2 (Wellness Director) had both stated that Resident 4 was moved to the "assisted living" from the Memory Care (MC) due to another resident in the MC targeting him/her. S/he also stated Resident 4 was moved back to the MC after the other resident had passed away. Staff 2 stated they were unaware of how long the resident was in the "AL" and to his/her knowledge, staffing was not increased to during that time. In a phone interview on 09/26/23, Staff 3 (ED) stated s/he was unaware if there was an assessment done or a new service plan put into place when the resident moved into the "AL".  S/he stated they would need to look through the documents. There was no evidence to indicate an assessment or service plan was completed when Resident 4 moved into the AL from the MC in August 2022. A review of progress notes dated August 2022 through April 2023, indicated Resident 4 was moved from the MC to AL on 08/30/22 and was moved back to the MC on 04/05/23. A progress note dated 08/30/22 at 12:44pm indicated that the facility had spoke to Resident 4's family member about trialing a move to the AL side to separate the 2 residents and s/he liked the idea. A progress note dated 02/15/23 at 3:30pm indicated a quarterly assessment was completed on 02/14/23 and that Resident 4 had very poor short-term memory and required frequent re-direction. CS reviewed Resident 4's service plans dated 10/12/21 and 03/03/23 which indicated the following: · "Resident not oriented to place or time" · "Does not have the ability to use or manage a key" · "Very poor short-term memory requiring frequent re-direction" · "Often exit seeks which can cause others in MC to exit seek as well" · "Wanders up and down hallways and will frequently ask where room is, for staff to show where the bathroom is, or when the next meal is" · Both service plans indicated Resident 4's MC room number , even during the time s/he was living in the AL. These findings were shared with Staff 2 and Staff 3 via email on 09/29/23. It was determined the facility failed to provide a safe and home-like environment. Verbal plan of correction: No plan of correction was provided”

“Based on interview and record review, conducted during a site visit on 09/22/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#2) whose records were reviewed. Findings include, but not limited to: Compliance Specialist reviewed Resident 2's Medication Administration Record (MAR), dated July 2023 through August 2023, and progress notes, doctor's orders, and incident form dated 08/05/23. The documents indicated between 07/23/23-07/29/23 and 08/03/23-08/05/23, Resident 1 was given half a dose of what was ordered for Lorazepam. This occurred 11 times before it was discovered. Progress notes dated 07/03/23 indicated that Resident 1 did not receive his/her 8 pm Tramadol 50 mg tab as ordered. The MT only administered one tab instead of two tabs on 07/01/23-07/02/23. In an interview, Staff 2 (Wellness Director) stated the pharmacy sent two medications, one for scheduled and one for PRN Lorazepam, at the same time and it was read wrong. The findings were reviewed with and acknowledged by Staff 2 on 09/22/23. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal plan of correction: Re-training has been done at MT meetings which occur monthly. Nurse went over the three checks with staff and reminders to check the orders. Facility started labeling the PRN Lorazepam so they don't get the two mixed up. Based on interview and record review, conducted during a site visit on 09/22/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of Resident 1's August 2023 Medication Administration Record (MAR) and progress notes indicated on 08/03/23 Resident 1 was given prior PRN Tylenol dose that was discontinued on 08/01/23. Compliance Specialist also reviewed faxes to his/her doctor and to APS dated 08/03/23 regarding the medication error. In an interview, Staff 2 (Wellness Director) stated the medication had  "just got discontinued and changed to scheduled instead of PRN" and "the med tech didn't check on the computer before giving". The findings were reviewed with and acknowledged by Staff 2 on 09/22/23. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal plan of correction: Re-training has been done at MT meetings which occur monthly. Nurse went over the three checks with staff and reminders to check the orders. Based on interview and record review, conducted during a site visit on 09/22/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#2) whose records were reviewed. Findings include, but not limited to: Compliance Specialist reviewed Resident 2's Medication Administration Record (MAR), dated July 2023 through August 2023, and progress notes, doctor's orders, and incident form dated 08/05/23. The documents indicated between 07/23/23-07/29/23 and 08/03/23-08/05/23, Resident 1 was given half a dose of what was ordered for Lorazepam. This occurred 11 times before it was discovered. Progress notes dated 07/03/23 indicated that Resident 1 did not receive his/her 8 pm Tramadol 50 mg tab as ordered. The MT only administered one tab instead of two tabs on 07/01/23-07/02/23. In an interview, Staff 2 (Wellness Director) stated the pharmacy sent two medications, one for scheduled and one for PRN Lorazepam, at the same time and it was read wrong. The findings were reviewed with and acknowledged by Staff 2 on 09/22/23. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal plan of correction: Re-training has been done at MT meetings which occur monthly. Nurse went over the three checks with staff and reminders to check the orders. Facility started labeling the PRN Lorazepam so they don't get the two mixed up. Based on interview and record review, conducted during a site visit on 09/22/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of Resident 1's August 2023 Medication Administration Record (MAR) and progress notes indicated on 08/03/23 Resident 1 was given prior PRN Tylenol dose that was discontinued on 08/01/23. Compliance Specialist also reviewed faxes to his/her doctor and to APS dated 08/03/23 regarding the medication error. In an interview, Staff 2 (Wellness Director) stated the medication had  "just got discontinued and changed to scheduled instead of PRN" and "the med tech didn't check on the computer before giving". The findings were reviewed with and acknowledged by Staff 2 on 09/22/23. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal plan of correction: Re-training has been done at MT meetings which occur monthly. Nurse went over the three checks with staff and reminders to check the orders.”

“Based on interview and record review, conducted during a site visit on 09/22/23, it was determined the facility failed to make records available to the Department upon request. Findings include, but are not limited to: In a phone interview on 09/26/23, Staff 3 (ED) stated they would look and see if there was an evaluation or service plan done when Resident 4 was moved from the MC to the AL, and would follow up with the Compliance Specialist (CS). In a phone call on 09/27/23, Staff 3 stated s/he would send the documents by the next morning. Compliance Specialist (CS) was not provided documentation of an assessment or service plan being completed in August 2022 when Resident 4 was moved from the MC to the AL during the onsite visit on 09/22/23. In review of emails sent on 09/26/23, 09/27/23, and 09/29/23 to Staff 3 (ED), the CS requested records of assessments or service plan updates between August 2022 and March 2023 documenting how the facility would be providing the care needed for Resident 4 outside of the MC.  The CS did not receive the records as requested. The findings were shared with Staff 2 (Wellness Director) and Staff 3 via email on 09/29/23. It was determined the facility failed to make records available to the Department upon request. Verbal plan of correction: No plan of correction was provided. Based on interview and record review, conducted during a site visit on 09/22/23, it was determined the facility failed to make records available to the Department upon request. Findings include, but are not limited to: In a phone interview on 09/26/23, Staff 3 (ED) stated they would look and see if there was an evaluation or service plan done when Resident 4 was moved from the MC to the AL, and would follow up with the Compliance Specialist (CS). In a phone call on 09/27/23, Staff 3 stated s/he would send the documents by the next morning. Compliance Specialist (CS) was not provided documentation of an assessment or service plan being completed in August 2022 when Resident 4 was moved from the MC to the AL during the onsite visit on 09/22/23. In review of emails sent on 09/26/23, 09/27/23, and 09/29/23 to Staff 3 (ED), the CS requested records of assessments or service plan updates between August 2022 and March 2023 documenting how the facility would be providing the care needed for Resident 4 outside of the MC.  The CS did not receive the records as requested. The findings were shared with Staff 2 (Wellness Director) and Staff 3 via email on 09/29/23. It was determined the facility failed to make records available to the Department upon request. Verbal plan of correction: No plan of correction was provided.”