The Rawlin at Riverbend.

“Based on interview and record review, it was determined the facility failed to immediately notify the local Senior and People with Disabilities (SPD) office when an incident of abuse, or suspected abuse, occurred, failed to report physical injuries of unknown cause to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, and failed to promptly investigate incidents for 3 of 3 sampled residents (#s 1, 2 and 6). Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure the evaluation described the resident's physical health status, mental status, and the environmental factors that helped the individual function at their optimal level, including data relevant to the residents' needs and current condition, and that move-in evaluations included all required elements, for 5 of 7 residents (#1, 4, 5, 6, and 7) whose evaluations were reviewed. Findings include, but are not limited to:”

“Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure service plans reflected residents’ needs as identified in their evaluations and/or lacked clear directions to staff for 5 of 7 residents (#s 1, 2, 5, 6, and 7) whose service plans were reviewed. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific interventions were determined and documented, actions or interventions were communicated to staff on each shift, and the condition was monitored with progress noted at least weekly until resolution for 4 of 6 sampled residents (#s 1, 2, 5, and 6) who experienced short-term changes of conditions. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual care plan and service plan for 5 of 7 sampled residents (#s 1, 2, 4, 5, and 6) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to: The facility's ABST was reviewed during the survey, 04/15/25 through 04/17/25. Review of Residents 1, 2, 4, 5, and 6’s ABST revealed multiple ADLs were not reflective of the residents' evaluated care needs. The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25. They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231. Refer to C231 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 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 C252, C260, C270 and C362. Refer to C252, C260, C270 and C362 OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:”

“The findings of the kitchen inspection, conducted 07/16/24, 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 kitchen inspection, conducted 07/16/24, 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 interview and record review, it was determined the facility failed to ensure physicians orders were carried out as prescribed for 3 of 5 sampled residents (#s 2, 4, and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia and high blood pressure. Resident 4's MARs for 03/01/24 and physician's orders were reviewed. Resident 4 had physician's orders for Metoprolol Tartrate 25 mg twice daily, to be held for systolic blood pressure less than 100. Resident 4's systolic blood pressure was documented to be below 100 in the morning on March 5th and 9th, and below 100 in the afternoon on March 9th and 19th. The Metoprolol Tartrate was not held as ordered. The need to ensure physician's orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (RN). They Acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure physicians orders were carried out as prescribed for 3 of 5 sampled residents (#s 2, 4, and 5) whose orders were reviewed. Findings include, but are not limited to:”

“The findings of the relicensure survey conducted 04/01/24 through 04/04/24 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the relicensure survey conducted 04/01/24 through 04/04/24 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the first re-visit to the re-licensure survey of 04/04/24, conducted 09/16/24 through 09/18/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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. Tag numbers beginning with the letter H refer to the Home & Community-Based Services rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day A situation was identified where there was a failure of the facility to comply with the Department's rules that was likely to cause a resident serious harm. An Immediate Plan of Correction was requested in the following area: OAR 411-054-0300 (11-13): Call System The facility put an Immediate Plan of Correction in place during the survey. The findings of the first re-visit to the re-licensure survey of 04/04/24, conducted 09/16/24 through 09/18/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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. Tag numbers beginning with the letter H refer to the Home & Community-Based Services rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day A situation was identified where there was a failure of the facility to comply with the Department's rules that was likely to cause a resident serious harm. An Immediate Plan of Correction was requested in the following area: OAR 411-054-0300 (11-13): Call System The facility put an Immediate Plan of Correction in place during the survey. The findings of the second revisit, to the re- licensure survey of 04/04/24, conducted 12/30/24 to 12/31/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. The findings of the second revisit, to the re- licensure survey of 04/04/24, conducted 12/30/24 to 12/31/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.”

“Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current status and care needs, and provided clear direction to staff regarding the delivery of services for 3 of  5 sampled residents (#s 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 02/2023 with diagnoses including Alzheimer's Disease, hypothyroidism, and heart failure. The resident's service plan, dated 01/11/24, was not reflective of the resident's current needs, or did not provide clear direction to staff in the following areas: * Assistance needed for activities; * Nutrition/ hydration, and eating assistance; * Side rails on bed; * Safety checks; and * Fall interventions. On 04/03/24, the need to ensure service plans were reflective of current status and provided clear directions for staff was discussed with Staff 1 (ED). She acknowledged the findings. Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current status and care needs, and provided clear direction to staff regarding the delivery of services for 3 of  5 sampled residents (#s 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to monitor resident injuries with weekly progress noted until the condition resolved, for 2 of 3 sampled residents (#s 1 and 4) with skin wounds. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia. The resident's record was reviewed and interviews were conducted with the resident and staff during the survey. On 02/09/24 a facility Progress Note indicated "Resident has a very small cut on [his/her] right hand. The cut is about less than a [centimeters] long in the shape of a C..." A Temporary Service Plan dated 02/09/24 was created for the injury and noted "Inner wrist right hand. About 2 cm long in the  shape of the letter C." There was no documented evidence the injury was evaluated to determine the accurate size. There was no documented evidence the injury had been monitored weekly to resolution. The need to ensure the changes in condition were evaluated and monitored with weekly progress noted until the condition was determined to be resolved was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings. Based on interview and record review, it was determined the facility failed to monitor resident injuries with weekly progress noted until the condition resolved, for 2 of 3 sampled residents (#s 1 and 4) with skin wounds. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure resident MARs included specific parameters and instructions for PRN medications, for 4 of 5 sampled residents (#s 2, 3, 4 and 5) whose MARs included multiple PRN medications used to treat the same condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2023 with diagnoses which included dementia and anxiety. Residents 3's orders and 03/01/24 through 04/01/24 MARs were reviewed. Resident 3 had orders for: * Acetaminophen 500 mg as needed for moderate pain; * Morphine Sulfate solution 5 mg as needed for pain; * Buspirone 5 mg as needed for anxiety; and * Lorazepam 0.5 mg as needed for anxiety. There were no resident specific parameters and instructions for which PRN medication to use first. The need to ensure there were clear parameters for unlicensed staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/02/24. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia. Residents 4's orders and 03/01/24 through 04/01/24 MARs were reviewed. Resident 4 had orders for: * Biofreeze gel 5%, apply to lower back as needed for low back pain; and * Voltaren gel 1%, APPLY 2 grams to lower back as needed for pain. There were no resident specific parameters and instructions for which PRN medication to use first. The need to ensure there were clear parameters for unlicensed staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/02/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure resident MARs included specific parameters and instructions for PRN medications, for 4 of 5 sampled residents (#s 2, 3, 4 and 5) whose MARs included multiple PRN medications used to treat the same condition. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure all direct care staff administering psychotropic medications knew the specific reasons for the use of the psychotropic medication for that resident, medications had written, resident-specific parameters, and non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 3 of 3 sampled residents (#s 1, 2, and 3) who had received psychotropic medications. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 10/2022 with diagnoses including dementia with behavioral disturbance, pain, and hypertension. S/he was subsequently admitted to hospice in 4/2024 with admitting diagnosis of Alzheimer's disease with behavioral disturbance. Review of Resident 2's clinical record indicated the following: * Resident 2 was prescribed haloperidol 0.5 ml as needed for delirium, nausea, and/or vomiting, and lorazepam 0.25 ml as needed for anxiety, restlessness, and shortness of breath; and * The MAR from 03/01/24 through 04/01/24 indicated staff administered four doses of PRN lorazepam and one dose of PRN haloperidol. There was no documented evidence the staff attempted and documented non-pharmacological interventions with ineffective results prior to administering the medication. The need to ensure non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 04/04/24. They acknowledged the findings. No further information was provided. Based on interview and record review, it was determined the facility failed to ensure all direct care staff administering psychotropic medications knew the specific reasons for the use of the psychotropic medication for that resident, medications had written, resident-specific parameters, and non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 3 of 3 sampled residents (#s 1, 2, and 3) who had received psychotropic medications. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired direct care staff (#s 7, 8, 9 and 10) had documented evidence of training in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 6 (Business Office Director) on 04/02/24. Staff 7 (CG), hired 12/14/23, Staff 8 (CG), hired on 02/16/24, Staff 9 (CG), hired 02/23/24, and Staff 10 (CG), hired 02/22/24, lacked documented evidence they had completed first aid and abdominal thrust training within 30 days of hire. Staff 6 acknowledged the staff had not been trained in First Aid or abdominal thrust. The need to ensure staff completed the required training within 30 days was reviewed with Staff 1 (ED) on 04/02/24. She acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired direct care staff (#s 7, 8, 9 and 10) had documented evidence of training in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 6 (Business Office Director) on 04/02/24. Staff 7 (CG), hired 12/14/23, Staff 8 (CG), hired on 02/16/24, Staff 9 (CG), hired 02/23/24, and Staff 10 (CG), hired 02/22/24, lacked documented evidence they had completed first aid and abdominal thrust training within 30 days of hire. Staff 6 acknowledged the staff had not been trained in First Aid or abdominal thrust. The need to ensure staff completed the required training within 30 days was reviewed with Staff 1 (ED) on 04/02/24. She acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Review of facility records on 04/02/24 identified the following deficiencies: There was no documented evidence that annual training on fire safety was provided to residents. On 04/02/24, the need to provide and document fire safety instruction to residents, at least annually, in accordance with the OFC was discussed with Staff 1 (ED). She acknowledged the findings. Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Review of facility records on 04/02/24 identified the following deficiencies: There was no documented evidence that annual training on fire safety was provided to residents. On 04/02/24, the need to provide and document fire safety instruction to residents, at least annually, in accordance with the OFC was discussed with Staff 1 (ED). She acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 260, C 270, C 303, C 310, and Z 164. Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 260, C 270, C 303, C 310, and Z 164. Refer to C260, C270, C303, C310 and Z 164 Refer to C260, C270, C303, C310 and Z 164 There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers. The current call system did not have a way to consistently alert caregiving staff when a call light was activated, which constituted a threat to the health, safety, and welfare of residents. Findings include, but are not limited to: During an interview on 09/17/24 at 11:00 am, Resident 10 revealed his/her call system in his/her room failed to work, and s/he used a wooden clapper to get the staff's attention because the call lights went unanswered. On 09/17/24 at 11:30 am, the pull cord in Resident 10's room was pulled.  At 12:15 pm the surveyor asked staff how they were alerted to resident call lights. Staff reported when a resident pulled a cord for assistance, the notification went to a call light panel located behind a locked door, and the MTs informed the caregivers of the call through their walkie talkies. When staff were asked if they had received notification Resident 10 had activated his/her call light, they stated no. No one responded to the call from 11:30 am to 1:00 pm. In an interview about the call system 09/17/24 at 12:25 pm, Staff 16 reported when she was near the call light panel, she would alert the caregivers of the room numbers that needed assistance. On 09/17/24 at 2:18 pm, surveyors discussed the call light system with Staff 1 (Executive Director). She reported tablets had been ordered for each neighborhood and they were "supposed to be able to download" an app to the tablets connecting them to the call system. She said that app would cue staff on each neighborhood that a resident's call light had been activated. Staff 1 stated the tablets were "enroute," and the system should be "up and running by the end of the week." She indicated some of the residents had call buttons worn on their wrist and some had call pendants, and that these devices were part of a "stand-alone system." Surveyors requested a list of all residents who had a wrist button or call pendant. Staff 1 reported the current call system had no way of tracking response time to call lights. She said the new system using the tablets would be able to track response time. Staff 1 indicated "someone was at the front" desk during "business hours," and it was part of the receptionist's duties to monitor the call panel and notify staff of call lights and follow-up to ensure they were answered. She said "all staff" should have walkie talkies so the MT, RCC, and receptionist could reach care staff to alert them to call lights. On 09/17/24, an observation of the call light panel showed that thirteen resident room emergency pull cords had been activated. There was no evidence the call system panel was being consistently monitored to alert staff when call lights went off. Call lights left unanswered placed the residents' health, safety, and welfare at risk. At 2:40 pm on 09/17/24 the facility was asked to provide an invoice or other documentation to show the tablets had been purchased. At 3:30 pm, Staff 1 reported she would have the list of residents with call buttons independent from the main system, as well as the documentation the tablets had been purchased, on the morning of 09/18/24. On 09/18/24 at 9:30 am a list of 10 of the 64 residents in the facility with call buttons independent from the main system was received, as well as an invoice for the tablets. The facility also provided an email from the corporate IT specialist, who wrote they would "have the ability to add more applications such as the call-light system in the future." When asked what "in the future" meant, Staff 1 said the app would be installed as soon as the tablets were received. She indicated that in the meantime hourly checks on every resident had been implemented. Surveyors requested a plan regarding how the facility would ensure residents' needs were met until the call system was consistently connected to the care staff center or staff pagers. A plan to have one staff responsible to check on all residents every 15 minutes, as well as scheduling the vendor to make the current call system audible on 09/23/24, was received on 09/18/24 at 12:47 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system(s) failures(s) associated with the licensing violation. The need to ensure the facility provided a call system that consistently connected resident units to the care staff center or staff pagers was discussed with Resident 1 (Executive Director) and Resident 13 (Asset Manager) on 09/18/24. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers. The current call system did not have a way to consistently alert caregiving staff when a call light was activated, which constituted a threat to the health, safety, and welfare of residents. Findings include, but are not limited to: During an interview on 09/17/24 at 11:00 am, Resident 10 revealed his/her call system in his/her room failed to work, and s/he used a wooden clapper to get the staff's attention because the call lights went unanswered. On 09/17/24 at 11:30 am, the pull cord in Resident 10's room was pulled.  At 12:15 pm the surveyor asked staff how they were alerted to resident call lights. Staff reported when a resident pulled a cord for assistance, the notification went to a call light panel located behind a locked door, and the MTs informed the caregivers of the call through their walkie talkies. When staff were asked if they had received notification Resident 10 had activated his/her call light, they stated no. No one responded to the call from 11:30 am to 1:00 pm. In an interview about the call system 09/17/24 at 12:25 pm, Staff 16 reported when she was near the call light panel, she would alert the caregivers of the room numbers that needed assistance. On 09/17/24 at 2:18 pm, surveyors discussed the call light system with Staff 1 (Executive Director). She reported tablets had been ordered for each neighborhood and they were "supposed to be able to download" an app to the tablets connecting them to the call system. She said that app would cue staff on each neighborhood that a resident's call light had been activated. Staff 1 stated the tablets were "enroute," and the system should be "up and running by the end of the week." She indicated some of the residents had call buttons worn on their wrist and some had call pendants, and that these devices were part of a "stand-alone system." Surveyors requested a list of all residents who had a wrist button or call pendant. Staff 1 reported the current call system had no way of tracking response time to call lights. She said the new system using the tablets would be able to track response time. Staff 1 indicated "someone was at the front" desk during "business hours," and it was part of the receptionist's duties to monitor the call panel and notify staff of call lights and follow-up to ensure they were answered. She said "all staff" should have walkie talkies so the MT, RCC, and receptionist could reach care staff to alert them to call lights. On 09/17/24, an observation of the call light panel showed that thirteen resident room emergency pull cords had been activated. There was no evidence the call system panel was being consistently monitored to alert staff when call lights went off. Call lights left unanswered placed the residents' health, safety, and welfare at risk. At 2:40 pm on 09/17/24 the facility was asked to provide an invoice or other documentation to show the tablets had been purchased. At 3:30 pm, Staff 1 reported she would have the list of residents with call buttons independent from the main system, as well as the documentation the tablets had been purchased, on the morning of 09/18/24. On 09/18/24 at 9:30 am a list ”

“Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 372 and C 422. Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 372 and C 422. Refer to C 372 and C 422 Refer to C 372 and C 422 Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 555. Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 555. Refer to C555 Refer to C555 There are no detail notes for this visit.”

“Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 260, C 270, 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 260, C 270, C 303, C 310 and C 330. Refer to C 260, C 270, C 303, C 310 and C 330 Refer to C 260, C 270, 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. This is a repeat citation. Findings include, but are not limited to: Refer to C 260, C 270, C 303, and C 310. Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 260, C 270, C 303, and C 310. Refer to C260, C270, C303 and C310 Refer to C260, C270, C303 and C310 There are no detail notes for this visit.”

“Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in service plans for 2 of 5 sampled residents (#s 2 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 02/2023, with diagnoses including Alzheimer's Disease, heart failure, and atrial fibrillation. In an acuity interview on 04/01/24, the resident was identified as needing physical assistance with eating. Review of Resident 5's service plan, dated 01/11/24, observations, and interviews with staff identified the following deficiencies: The dining portion of Resident 5's service plan lacked the following information: * Food and fluid preferences; * Individual needs or adaptations, to allow the resident the greatest independence possible; and * A set process or program, to provide hydration and nutrition to the resident between meals. On 04/03/24, the need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED). She acknowledged the findings. Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in service plans for 2 of 5 sampled residents (#s 2 and 5) whose service plans were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose activity plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3, 4, and 5's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect the following required components: *Residents' current preferences; *Abilities and skills; *Emotional/social needs and patterns; *Physical abilities and limitations; *Adaptations necessary for the resident to participate; and *Identification of activities for behavioral interventions. There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities. The need to evaluate and develop individualized activity plans, including all required components for each memory care resident, was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/02/24 and 04/03/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose activity plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3, 4, and 5's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect the following required components: *Residents' current preferences; *Abilities and skills; *Emotional/social needs and patterns; *Physical abilities and limitations; *Adaptations necessary for the resident to participate; and *Identification of activities for behavioral interventions. There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities. The need to evaluate and develop individualized activity plans, including all required components for each memory care resident, was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/02/24 and 04/03/24. They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 2 sampled residents (#4) with documented behaviors. Findings include, but are not limited to: Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia. Resident 4's record documented behaviors including physical altercations with other residents. The resident's service plan, dated 01/04/24, did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 04/02/24 and 04/03/24, the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED) and Staff 3 (RCC). They acknowledged the findings. Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 2 sampled residents (#4) with documented behaviors. Findings include, but are not limited to: Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia. Resident 4's record documented behaviors including physical altercations with other residents. The resident's service plan, dated 01/04/24, did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 04/02/24 and 04/03/24, the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED) and Staff 3 (RCC). They acknowledged the findings.”

“The findings of the on-site investigation, conducted 01/10/24, 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, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT: Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse The findings of the on-site investigation, conducted 01/10/24, 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, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT: Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse”

“The findings of the on-site investigation, conducted 01/10/24, 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, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT: Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse The findings of the on-site investigation, conducted 01/10/24, 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, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT: Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse”

“The findings of the kitchen inspection, conducted 9/8/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the kitchen inspection, conducted 9/8/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the first re-visit to the kitchen re-licensure survey of 09/08/23, conducted on 11/08/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the first re-visit to the kitchen re-licensure survey of 09/08/23, conducted on 11/08/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.”

“Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen areas were reviewed on 9/8/23 from 10:45 am through 2:30 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Fans blades and cages in cooler; * Ceiling in walk in cooler; * Ceiling vents and ceiling surrounding vents; * Industrial mixer; * Interior of unit microwaves; * Unit reach in refrigerators/freezers; * Half walls of unit dining areas; * Cupboards where food stored in activity space; * Oven in activity space; * Areas around facets in all kitchenettes with mold like residue; and * Carpet rug in one of kitchenettes was dirty. b. The following areas were in need of repair: * Walk in freezer door, ceiling and racks with ice build up; * Unit kitchenettes and dining area walls with pealing/scratched/scuffed paint; * Janitor closet in kitchen with pealing/missing paint, small hole in wall; * Unit reach in refrigerators with damage to inside. One with door seal detached; * Caulking around handwashing sink damaged/missing/in need replacement. c. Multiple cutting boards, plastic storage containers with damage or heavy scoring and staining rendering items not to be smooth and cleanable as required. Oven mitts in kitchen found with rips and tears exposing cloth padding. Small fry pan damaged and in need of replacement. d. Microwaves in kitchen and multiple kitchenettes with staining, rusting and protective coating pealing. e. Ready To Eat (RTE) food items (Rice Krispy treat and cookie) found stored in unit drawer uncovered and exposed to potential contamination. Drawer with visible food debris. f. Multiple unit refrigerators without thermometers to monitor temperatures to ensure food items stored at 41 degrees F or less. Fridge in Daisy unit had a thermometer but when checked was at 48 degrees F. Milk stored in that refrigerator was checked and temperature was at 45 degrees F. Facility did not have a process for staff to monitor temperatures of unit refrigerators to ensure cold food items were stored at appropriate temperatures. Items in that refrigerator were discarded. Staff 2 (Dietary Manager) toured the kitchen areas with the surveyor and acknowledged the findings. At approximately 2:00 pm, the surveyor reviewed above areas with Staff 1 (Executive Director) who acknowledged the findings. Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen areas were reviewed on 9/8/23 from 10:45 am through 2:30 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Fans blades and cages in cooler; * Ceiling in walk in cooler; * Ceiling vents and ceiling surrounding vents; * Industrial mixer; * Interior of unit microwaves; * Unit reach in refrigerators/freezers; * Half walls of unit dining areas; * Cupboards where food stored in activity space; * Oven in activity space; * Areas around facets in all kitchenettes with mold like residue; and * Carpet rug in one of kitchenettes was dirty. b. The following areas were in need of repair: * Walk in freezer door, ceiling and racks with ice build up; * Unit kitchenettes and dining area walls with pealing/scratched/scuffed paint; * Janitor closet in kitchen with pealing/missing paint, small hole in wall; * Unit reach in refrigerators with damage to inside. One with door seal detached; * Caulking around handwashing sink damaged/missing/in need replacement. c. Multiple cutting boards, plastic storage containers with damage or heavy scoring and staining rendering items not to be smooth and cleanable as required. Oven mitts in kitchen found with rips and tears exposing cloth padding. Small fry pan damaged and in need of replacement. d. Microwaves in kitchen and multiple kitchenettes with staining, rusting and protective coating pealing. e. Ready To Eat (RTE) food items (Rice Krispy treat and cookie) found stored in unit drawer uncovered and exposed to potential contamination. Drawer with visible food debris. f. Multiple unit refrigerators without thermometers to monitor temperatures to ensure food items stored at 41 degrees F or less. Fridge in Daisy unit had a thermometer but when checked was at 48 degrees F. Milk stored in that refrigerator was checked and temperature was at 45 degrees F. Facility did not have a process for staff to monitor temperatures of unit refrigerators to ensure cold food items were stored at appropriate temperatures. Items in that refrigerator were discarded. Staff 2 (Dietary Manager) toured the kitchen areas with the surveyor and acknowledged the findings. At approximately 2:00 pm, the surveyor reviewed above areas with Staff 1 (Executive Director) who acknowledged the findings. A. 1. A detailed cleaning checklist including the following areas will be created for the Dining Services team to complete: Fan blades and cages in cooler, ceiling vents and ceiling surrounding the vents, the industrial mixer, interiors of kitchen and unit microwaves, interiors of kitchen and unit refrigerators and freezers, half walls of unit dining areas, cupboards where food is stored in the activity space, the oven in the activity space, areas surrounding the faucets in the kitchen and units and the carpet rugs in the unit kitchenettes. 2. Training of current and new members of the Dining Services team will include a review of the cleaning checklists as a building procedure. Employees will be required to sign the cleaning checklist as an ackowledgement of the expectations. 3.The areas that have been listed that need correction will be evaluated on a weekly basis moving forward. 4. The Dietary Services Director and Maintenance Director will monitor the completion of the corrections listed. B. 1. Repair of the following areas will be tasked to the Maintenance Director: Walk-in freezer door, ceiling and racks ice build-up- call to manufacturer of walk-in freezer seeking local repair assistance. Thorough removal of existing ice build-up. Unit kitchenettes and dining area walls that have pealing/scratches/scuffed paint- Fresh paint and kick-guard will be installed to prevent further damage. Janitor closet in kitchen with pealing/missing paint, also with a small hole in the wall- All items will be removed from the closet for a fresh coat of paint and repair/patch for the hole. When items are put back in the closet they will be well-organized. Unit reach-in refrigerators with damage- All unit refrigerators will be replaced. Caulking around handwashing sink is damaged/missing- Kitchenette sinks will be deep cleaned and re-caulked. 2. The areas that were in violation will be added to TELS (tracking software for maintenance/upkeep of community) as a task/review for the Maintenance Director. 3. The TELS tasks will be scheduled monthly. 4. The Executive Director will review completion of the tasks with the Maintenance Director. C. 1. Inventory of kitchen food preparation products will be completed and will note the specific items needing repair. Items that were listed included: cutting boards, plastic storage containers, oven mitts, small fry pans. Once items inventoried, replacements will be ordered. 2. Preparation product inventory will be implemented as a standard practice moving forward. 3. Product inventory will be evaluated monthly. 4. The Dining Services Director will review needs and order with Executive Director. D. 1. Unit microwaves as well as m”

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

“The findings of the on-site investigation, conducted 08/08/23, 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, OARs 411 Division 57 for Memory Care Communities. The findings of the on-site investigation, conducted 08/08/23, 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, OARs 411 Division 57 for Memory Care Communities.”

“Based on interview and record review, conducted during a site visit on 08/08/23, it was confirmed the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse for 1 of 1 sampled resident (#8). Findings include, but are not limited to: A review of Resident 8's progress notes revealed on 04/03/23, s/he was on alert for a resident-to-resident altercation resulting in a "possible head injury" from another resident headbutting him/her. There was no other documentation provided regarding the incident or evidence of an internal investigation. A review of an email sent to the Licensing Complaint Unit on 07/05/23 by APS confirmed the incident had not been reported. In an interview on 08/08/23 Staff 1 (Business Office Manager) stated anytime a resident puts hands on another resident, there should have been an incident report filled out and an internal investigation done. Staff 3 (Resident Care Coordinator) stated it had been reported to the ED. The above information was shared with Staff 1 (Business Office Manager) on 08/08/23. S/he acknowledged the findings. It was determined the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse. Verbal pan of correction: Re-training for RCCs and Nurses on Abuse reporting will be done within 30 days. The ED and Business office manager will be responsible for auditing incidents to ensure that resident to resident altercations and any suspected abuse/neglect is being reported to APS. Based on interview and record review, conducted during a site visit on 08/08/23, it was confirmed the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse for 1 of 1 sampled resident (#8). Findings include, but are not limited to: A review of Resident 8's progress notes revealed on 04/03/23, s/he was on alert for a resident-to-resident altercation resulting in a "possible head injury" from another resident headbutting him/her. There was no other documentation provided regarding the incident or evidence of an internal investigation. A review of an email sent to the Licensing Complaint Unit on 07/05/23 by APS confirmed the incident had not been reported. In an interview on 08/08/23 Staff 1 (Business Office Manager) stated anytime a resident puts hands on another resident, there should have been an incident report filled out and an internal investigation done. Staff 3 (Resident Care Coordinator) stated it had been reported to the ED. The above information was shared with Staff 1 (Business Office Manager) on 08/08/23. S/he acknowledged the findings. It was determined the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse. Verbal pan of correction: Re-training for RCCs and Nurses on Abuse reporting will be done within 30 days. The ED and Business office manager will be responsible for auditing incidents to ensure that resident to resident altercations and any suspected abuse/neglect is being reported to APS.”