Brookdale Troutdale.

“Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 03/12/24.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health HS: Hours of sleep LPN: Licensed Practical Nurse MT:            Medication Technician or Med 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 SP: Service plan SPT: Service Planning Team TAR: Treatment Administration Record Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 03/12/24.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health HS: Hours of sleep LPN: Licensed Practical Nurse MT:            Medication Technician or Med 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 SP: Service plan SPT: Service Planning Team TAR: Treatment Administration Record”

“Based on observation, interview, and record review, conducted during a site visit on 03/12/25, the facility's failure to consistently have qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to: The facility was divided into two distinct and segregated neighborhoods, Clare and Bridge. The facility's posted staffing plan, dated 03/04/25, indicated: *For Clare, four caregivers and one med tech on day shift, three caregivers and one med tech on swing shift, and one caregiver and one med tech that was shared with Bridge. *For Bridge, four caregivers and one med tech on day shift, two caregivers and one med tech on swing shift, and one caregiver and one med tech that was shared with Clare House. On 03/12/25, in Clare, there were two caregivers and one med tech observed on day shift. In Bridge, there were four caregivers and one med tech observed on day shift. The facility's staff schedule, dated 03/05/25 through 03/12/25 indicated from 03/06/25 through 03/12/25, for Clare and Bridge, there were eight instances where the facility was not staffing according to their posted staffing plan. Staff 1 (Executive Director) stated there were 11 residents who required the assistance of two staff members for care in Clare and Bridge. The facility's posted staffing plan did not account for the number of staff for residents who required two staff members for care. It was determined the facility's failure to consistently have qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. The findings of the investigation were reviewed with or acknowledged by Staff 1 and Staff 2 (District Director of Operations) on 03/28/25 via virtual conference. Based on observation, interview, and record review, conducted during a site visit on 03/12/25, the facility's failure to consistently have qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to: The facility was divided into two distinct and segregated neighborhoods, Clare and Bridge. The facility's posted staffing plan, dated 03/04/25, indicated: *For Clare, four caregivers and one med tech on day shift, three caregivers and one med tech on swing shift, and one caregiver and one med tech that was shared with Bridge. *For Bridge, four caregivers and one med tech on day shift, two caregivers and one med tech on swing shift, and one caregiver and one med tech that was shared with Clare House. On 03/12/25, in Clare, there were two caregivers and one med tech observed on day shift. In Bridge, there were four caregivers and one med tech observed on day shift. The facility's staff schedule, dated 03/05/25 through 03/12/25 indicated from 03/06/25 through 03/12/25, for Clare and Bridge, there were eight instances where the facility was not staffing according to their posted staffing plan. Staff 1 (Executive Director) stated there were 11 residents who required the assistance of two staff members for care in Clare and Bridge. The facility's posted staffing plan did not account for the number of staff for residents who required two staff members for care. It was determined the facility's failure to consistently have qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. The findings of the investigation were reviewed with or acknowledged by Staff 1 and Staff 2 (District Director of Operations) on 03/28/25 via virtual conference.”

“The findings of the re-licensure survey, conducted 04/22/24 through 04/24/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the re-licensure survey, conducted 04/22/24 through 04/24/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the first revisit to the re-licensure survey of 04/22/24, conducted 10/01/24 through 10/03/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the first revisit to the re-licensure survey of 04/22/24, conducted 10/01/24 through 10/03/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the second revisit to the re-licensure survey of 04/24/24, conducted 03/03/25 through 03/04/25, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the second revisit to the re-licensure survey of 04/24/24, conducted 03/03/25 through 03/04/25, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the third revisit to the re-licensure survey of 04/24/24, conducted 04/30/25, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. The findings of the third revisit to the re-licensure survey of 04/24/24, conducted 04/30/25, are documented in this report. It was determined the facility was in substantial compliance wi”

“Based on observation and interview, it was determined the facility failed to ensure establishment and maintenance of infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 2 of 2 sampled residents (#s 1 and 4) related to incontinence care. Findings include, but are not limited to: 1. Resident 4 moved into the memory care community in 09/2021 with diagnoses including Alzheimer's Disease. Observations and interviews with staff during the survey identified s/he relied on two staff for transfers and incontinence care needs. On 04/23/24 at 11:23 am, Staff 7 (MT) and Staff 14 (CG) were observed providing ADL incontinence care for Resident 4. Staff 7 and Staff 14 donned gloves without first performing hand hygiene. Staff 7 and Staff 14 assisted in transferring Resident 4 from Geri chair to bed, and then doffed his/her pants and brief. Staff 14 identified the resident's brief was soiled with urine, removed the brief, and placed it into a trash bag. Staff 7 provided perineal care and placed a new brief without performing hand hygiene or a glove change between tasks. Staff 14 changed gloves without performing hand hygiene and assisted Staff 7 in dressing Resident 4. Both staff transferred Resident 4 back to the Geri chair, and Staff 14 placed a blanket on Resident 4. Both staff doffed gloves after assisting Resident 4 and were not observed to perform hand hygiene at the completion of providing assistance. The surveyor requested the staff perform hand hygiene prior to exiting Resident 4's apartment, which was completed. The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24 at 2:30 pm. Based on observation and interview, it was determined the facility failed to ensure establishment and maintenance of infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 2 of 2 sampled residents (#s 1 and 4) related to incontinence care. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure the MAR had written resident-specific parameters, non-pharmacological interventions for PRN psychotropic medications and failed to ensure non-pharmacological interventions had been tried and documented with ineffective results prior to administering PRN psychotropic medications for 3 of 3 sampled residents (#s 3, 5 and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the memory care community in 03/2023 with diagnoses including Alzheimer's disease with late onset and dementia. a. A review of the MAR dated 04/01/24 through 04/21/24 and progress notes for the same time period identified the following: Resident 5 was prescribed lorazepam 2mg/0.5ml (1mg) by mouth every four hours as needed for anxiety. Unlicensed staff administered the PRN psychotropic medication on 04/02/24, 04/04/24 and 04/08/24. There was no documented evidence non-pharmacological interventions had been tried with ineffective results prior to administering the medication. b. Resident 5 was prescribed risperidone 0.25mg tablet, give one tablet by mouth, twice daily as needed for agitation. The MAR lacked written resident specific non-pharmacological interventions to attempt prior to administration of the PRN medication. The 04/01/24 through 04/21/24 MAR identified unlicensed staff did not administer the risperidone medication to the resident. The need to ensure the MAR had non-pharmacological interventions for unlicensed staff to attempt prior to administering a PRN psychotropic and the need to ensure staff documented non-pharmacological interventions were attempted with ineffective results prior to administering a PRN psychotropic was reviewed with Staff 2 (RN, Health and Wellness Director) on 04/23/24 and Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings. 2. Resident 6 moved into the memory care community in 04/2024 with diagnoses including unspecified dementia. A review of the MAR dated 04/09/24 through 04/21/24 and progress notes for the same time period identified the following: Resident 6 was prescribed olanzapine 2.5 mg tablet, give one tablet, twice daily, as needed for agitation. On 04/10/24 an unlicensed staff administered the PRN medication. There was no documented evidence for the reason staff administered the PRN medication or that non-pharmacological interventions had been tried with ineffective results prior to administering the medication. The need to ensure non-pharmacological interventions were attempted and documented with ineffective results prior to administering a PRN psychotropic medication was discussed with Staff 2 (RN, Health and Wellness Director) on 04/23/24 and Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure the MAR had written resident-specific parameters, non-pharmacological interventions for PRN psychotropic medications and failed to ensure non-pharmacological interventions had been tried and documented with ineffective results prior to administering PRN psychotropic medications for 3 of 3 sampled residents (#s 3, 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:”

“Concerns were identified and the facility was provided with technical assistance in the following areas: (1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule. Concerns were identified and the facility was provided with technical assistance in the following areas: (1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule. There are no detail notes for this visit.”

“Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C 231, C 361, C 365, C 420, C 422, C 510 and C 513. Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C 231, C 361, C 365, C 420, C 422, C 510 and C 513. Refer to the plans of corrections submitted for C231, C361, C365, C420, C422, C510, C513 Refer to the plans of corrections submitted for C231, C361, C365, C420, C422, C510, C513 Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 155, C 231, and C 361. 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 155, C 231, and C 361. Refer to plans of corrections submitted for C155, C231, C361 Refer to plans of corrections submitted for C155, C231, C361 Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to: C 513. Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to: C 513. Refers to C513 Refers to C513 There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly-hired staff (#s 8 and 15) completed all required pre-service orientation prior to providing care; 1 of 3 sampled staff (#8) failed to demonstrate competency before providing personal care, 3 of 3 long term staff (#s 9, 15, and 16) completed annual training as required, and that one of two sampled staff (#9) demonstrated competency prior to providing medication pass independently.  Findings include but are not limited to: Staff training records were reviewed with Staff 4 (Business Office Coordinator) on 04/23/24 and 04/24/24. The following was identified: 1. The following staff did not have documented evidence of completing the following pre-service training prior to providing personal care independently: a. Staff 8 (Med Tech/Caregiver) hired on 01/08/24: * Environmental factors important to a resident's well being; and * Family support and the role family may have in the care of the resident. b. Staff 15 (Caregiver) hired on 11/19/21: * How to provide care to a resident with dementia including an orientation to the resident's service plan. 2. There was not documented evidence the following staff demonstrated competency in the following areas within 30 days of hire or prior to providing care independently: a. Staff 8 (Caregiver) hired on 01/08/24: * Providing assistance with ADL's; * Changes associated with normal aging; and * Conditions that require assessment, treatment, observation and reporting. b. Staff 9 (Med Tech) hired on 09/15/21: * Medication Pass 3. There was no documented evidence Staff 9 (Med Tech) hired 09/15/21,  Staff 16 (Caregiver) hired on 11/01/12, and Staff 15 (Caregiver) hired on 11/19/21 had completed the required number of annual in-service training hours, including annual infectious disease training and at least six hours of training related to dementia care. The need to ensure the required pre-service and annual training was completed by staff in the time frames specified in the rules, as well as the need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 (ED), Staff 4 (Business Office Coordinator) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly-hired staff (#s 8 and 15) completed all required pre-service orientation prior to providing care; 1 of 3 sampled staff (#8) failed to demonstrate competency before providing personal care, 3 of 3 long term staff (#s 9, 15, and 16) completed annual training as required, and that one of two sampled staff (#9) demonstrated competency prior to providing medication pass independently.  Findings include but are not limited to: Staff training records were reviewed with Staff 4 (Business Office Coordinator) on 04/23/24 and 04/24/24. The following was identified:”

“Based on interview and record review, it was determined the facility failed to ensure complete and accurate records were maintained and records were not falsified for 1 of 1 sampled resident (#8) whose records were reviewed.  Findings include, but are not limited to: Resident 8 moved into the memory care community in 04/2024 with diagnoses including dementia. Review of Resident 8's records including 09/01/24 through 10/01/24 MARs were reviewed during the survey and interviews with staff were conducted. Observations of the resident during the survey identified s/he required meal assistance from staff for all nutrition and hydration. Review of the MARs instructed unlicensed staff to give protein shakes and ice water four times per day after meals and at bedtime for weight gain with administration times at 9:00 am, 1:00 pm, 5:00 pm, and 8:00 pm. Observations and interviews with multiple staff throughout the survey from 10/01/24 through 10/03/24 identified staff were not consistently providing the protein shakes and ice water as ordered however, the MARs were being initialed that protein shakes and ice water were being given. During an interview on 10/02/24 at 1:30 pm with Staff 1 (ED) and Staff 28 (Regional RN) the above concerns were discussed. During an interview on 10/03/24 at 8:50 am with Staff 1 and Staff 28 it was reported they interviewed staff, provided education and wrote a TSP for staff to do the following: * Make sure the resident drinks water approximately every two hours; and * "Offer protein drinks as ordered. Don't sign off that boost was consumed if the resident does not drink it." The need to ensure accurate resident records were kept and were not falsified was discussed with Staff 1 and Staff 28 on 10/02/24 at 1:30 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure complete and accurate records were maintained and records were not falsified for 1 of 1 sampled resident (#8) whose records were reviewed.  Findings include, but are not limited to: Resident 8 moved into the memory care community in 04/2024 with diagnoses including dementia. Review of Resident 8's records including 09/01/24 through 10/01/24 MARs were reviewed during the survey and interviews with staff were conducted. Observations of the resident during the survey identified s/he required meal assistance from staff for all nutrition and hydration. Review of the MARs instructed unlicensed staff to give protein shakes and ice water four times per day after meals and at bedtime for weight gain with administration times at 9:00 am, 1:00 pm, 5:00 pm, and 8:00 pm. Observations and interviews with multiple staff throughout the survey from 10/01/24 through 10/03/24 identified staff were not consistently providing the protein shakes and ice water as ordered however, the MARs were being initialed that protein shakes and ice water were being given. During an interview on 10/02/24 at 1:30 pm with Staff 1 (ED) and Staff 28 (Regional RN) the above concerns were discussed. During an interview on 10/03/24 at 8:50 am with Staff 1 and Staff 28 it was reported they interviewed staff, provided education and wrote a TSP for staff to do the following: * Make sure the resident drinks water approximately every two hours; and * "Offer protein drinks as ordered. Don't sign off that boost was consumed if the resident does not drink it." The need to ensure accurate resident records were kept and were not falsified was discussed with Staff 1 and Staff 28 on 10/02/24 at 1:30 pm. They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure investigations into physical injuries of unknown cause were documented to include that the physical injury was not the result of abuse for 2 of 3 sampled residents (#s 1 and 4) with injuries of unknown cause. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2023 with diagnoses including dementia with mood disturbance. The resident was noted to require the assistance of two staff for ADL cares. Review of the resident's 01/25/24 through 04/22/24 progress notes showed the following: * 01/31/24 "[Resident] is on alert charting for skin tear to the right hand middle and pointer fingers...doesn't remember how it happened." In a 04/24/24 interview with Staff 2 (RN, Health and Wellness Director), she stated an immediate investigation into the injuries concluded the injuries were not the result of abuse or neglect to Resident 1, however there was no documentation to support the conclusion. The need to ensure investigations into physical injuries of unknown cause were documented to include the injuries were not the result of abuse or neglect was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations). They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure investigations into physical injuries of unknown cause were documented to include that the physical injury was not the result of abuse for 2 of 3 sampled residents (#s 1 and 4) with injuries of unknown cause. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to provide services to assist residents in activities of daily living for 1 of 1 sampled resident (#8) who required staff assistance. Findings include, but are not limited to: Resident 8 moved into the memory care community in 04/2024 with diagnoses including dementia. The resident was observed to need staff assistance for all nutrition and hydration, required assistance from two care staff for transfers and mobility including repositioning, and bowel and bladder management. The resident's service plan dated 08/18/24, subsequent temporary service plans (TSP's) and 09/01/24 through 10/01/24 MARs instructed staff to perform the following ADL tasks: * Reposition every two hours if s/he was unable to self-adjust in the geri-chair; * Use a gait belt for all transfers; * Please check and provide incontinent care every two to three hours; * Please add butter and gravy to puree food; * Push fluids- water, juice, broth, tea, etc.; * Provide a high calorie dessert, sweets and ice cream; and * Give protein shakes and ice water four times per day after meals and at bedtime for weight gain with administration times at 9:00 am, 1:00 pm, 5:00 pm, and 8:00 pm. Observations made during the survey from 10/01/24 through 10/03/24 identified the following: * The resident was not observed to be able to self-adjust in the geri-chair; * The resident was unable to use the call light system; * The resident did not request food or fluids unless prompted by staff; * Staff were not observed to provide a protein shake, protein supplement added to any fluids, a high calorie dessert such as ice cream or sweets were not offered, per the service planned weight loss interventions; * Staff were not observed to provide any fluids on 10/02/24 from 8:39 am until 12:17 pm when lunch was served; * Staff were not observed to use a gait belt for safety when transferring the resident; * Staff were not observed to reposition the resident every two hours; and * Staff were not observed to provide incontinent care every two to three hours as instructed. During an interview on 10/02/24 at 10:54 am with Staff 13 (Kitchen Manager) it was reported Resident 8 was not receiving a protein powder shake with fresh fruit from the kitchen. Staff 13 stated "we don't prepare that for any residents. I don't even have protein powder. I usually put extra gravy on the mechanical soft diets, I don't do that for puree diet. I only have a TSP for Resident 8 to receive a puree diet, that is it." During an interview on 10/02/24 at 1:30 pm with Staff 1 (ED) and Staff 28 (Regional RN) the above findings were discussed. Staff 1 provided survey with a TSP that clarified ADL instructions for care staff to follow. Based on observation, interview, and record review, it was determined the facility failed to provide services to assist residents in activities of daily living for 1 of 1 sampled resident (#8) who required staff assistance. Findings include, but are not limited to: Resident 8 moved into the memory care community in 04/2024 with diagnoses including dementia. The resident was observed to need staff assistance for all nutrition and hydration, required assistance from two care staff for transfers and mobility including repositioning, and bowel and bladder management. The resident's service plan dated 08/18/24, subsequent temporary service plans (TSP's) and 09/01/24 through 10/01/24 MARs instructed staff to perform the following ADL tasks: * Reposition every two hours if s/he was unable to self-adjust in the geri-chair; * Use a gait belt for all transfers; * Please check and provide incontinent care every two to three hours; * Please add butter and gravy to puree food; * Push fluids- water, juice, broth, tea, etc.; * Provide a high calorie dessert, sweets and ice cream; and * Give protein shakes and ice water four times per day after meals and at bedtime for weight gain with administration times at 9:00 am, 1:00 pm, 5:00 pm, and 8:00 pm. Observations made during the survey from 10/01/24 through 10/03/24 identified the following: * The resident was not observed to be able to self-adjust in the geri-chair; * The resident was unable to use the call light system; * The resident did not request food or fluids unless prompted by staff; * Staff were not observed to provide a protein shake, protein supplement added to any fluids, a high calorie dessert such as ice cream or sweets were not offered, per the service planned weight loss interventions; * Staff were not observed to provide any fluids on 10/02/24 from 8:39 am until 12:17 pm when lunch was served; * Staff were not observed to use a gait belt for safety when transferring the resident; * Staff were not observed to reposition the resident every two hours; and * Staff were not observed to provide incontinent care every two to three hours as instructed. During an interview on 10/02/24 at 10:54 am with Staff 13 (Kitchen Manager) it was reported Resident 8 was not receiving a protein powder shake with fresh fruit from the kitchen. Staff 13 stated "we don't prepare that for any residents. I don't even have protein powder. I usually put extra gravy on the mechanical soft diets, I don't do that for puree diet. I only have a TSP for Resident 8 to receive a puree diet, that is it." During an interview on 10/02/24 at 1:30 pm with Staff 1 (ED) and Staff 28 (Regional RN) the above findings were discussed. Staff 1 provided survey with a TSP that clarified ADL instructions for care staff to follow.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident's current status and care needs, provided clear instruction regarding the delivery of services and were implemented for 3 of 5 sampled residents (#s 1, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the memory care community in 03/2023 with diagnoses including Alzheimer's disease with late onset and dementia. A review of the resident's clinical record, including a review of the service plan dated 01/25/24, temporary service plans, interviews with staff and observations of the resident's care was conducted during the survey. The following areas were not reflective of the resident's current status and care needs and did not provide clear instructions for staff: * One-to-two person transfers and use of a gait belt; * Mobility; * Cognitive/Psychosocial; * Reluctance to accept care; * Nutrition including meal refusals and meal assistance needed; * History of weight loss and weight loss interventions; * Behavior Management including exit seeking; * Hospice and services that were provided; * Use of a variable pressure mattress; and * Use of a foam wedge while in bed. The need to ensure service plans were reflective of the resident's current status and care needs, provided clear instruction regarding the delivery of services was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident's current status and care needs, provided clear instruction regarding the delivery of services and were implemented for 3 of 5 sampled residents (#s 1, 4 and 5) 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 short term changes of condition, had actions or interventions determined and communicated to staff on each shift and the conditions monitored with weekly progress noted until resolution for 3 of 6 sampled residents (#1, 4, and 5) who experienced short term changes of condition. Findings include, but are not limited to: 1.  Resident 1 was admitted to the facility in 10/2023 with diagnoses including dementia with mood disorder. a. Review of the 01/22/24 through 04/22/24 progress notes, 02/22/24 service plan, and Temporary Service Plans (TSP's) revealed Resident 1 experienced the following short-term changes of condition: * 02/21/24 - Medication order, increase sertraline (for depression) to 50 mg once daily; * 03/05/24 - Medication order, start cephalexin (for leg ulcer) 500 mg four times per day; and * 04/07/24 - Fall. The facility lacked documented evidence actions or interventions were developed and communicated to staff on each shift for the 04/07/24 fall and changes of condition were monitored, with progress noted at least weekly through resolution, for the 02/21/24 and 03/05/24 medication changes. The need to ensure each of Resident 1's short term changes of condition had interventions developed, communicated to staff on each shift and the conditions were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure short term changes of condition, had actions or interventions determined and communicated to staff on each shift and the conditions monitored with weekly progress noted until resolution for 3 of 6 sampled residents (#1, 4, and 5) who experienced short term changes of condition. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment for 4 of 4 sampled residents (#s 1, 2, 4 and 5) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 5 moved into the memory care community in 03/2023 with diagnoses including Alzheimer's disease with late onset and dementia. During the entrance acuity interview on 04/22/24, review of the resident roster identified Resident 5 was receiving hospice services. A review of the resident's clinical record, including charting notes dated 01/25/24 through 04/15/24, temporary service plans for the same time period and interviews with staff was conducted during the survey and identified the following: Resident 5 had a decline in ADL ability which included an admission to hospice on 02/29/24. This constituted a significant change of condition that required an RN assessment. There was no documented evidence a significant change of condition assessment was completed by an RN, including findings, resident status and interventions made as a result of the assessment. On 04/23/24, Staff 2 (RN, Director of Health and Wellness) reported she was aware of the resident's decline and hospice admission however, she did not document an assessment of the resident's significant change in condition. The need to ensure an RN assessed all significant changes of condition, including findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment for 4 of 4 sampled residents (#s 1, 2, 4 and 5) who experienced significant changes of condition. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to: The facility's ABST was reviewed on 04/23/24. There was no documented evidence all 22 required activities of daily living were addressed separately on the ABST used by the facility. The need to use an ABST which addressed all of the 22 activities of daily living for each resident and the amount of staff time needed to provide care was discussed with Staff 1 (ED) on 04/24/24. She acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to: The facility's ABST was reviewed on 04/23/24. There was no documented evidence all 22 required activities of daily living were addressed separately on the ABST used by the facility. The need to use an ABST which addressed all of the 22 activities of daily living for each resident and the amount of staff time needed to provide care was discussed with Staff 1 (ED) on 04/24/24. She acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to maintain documentation regarding each direct care staff's demonstrated competency and maintain written documentation of all training's completed by each employee. Findings include, but are not limited to: During a review of staff training records on 04/23/24 and 04/24/24, Staff 4 (Business Office Coordinator) was unable to provide documented evidence that sampled staff administering medications and providing personal care had completed pre-service dementia training and demonstrated competency in all duties they were assigned before working independently with residents including: * Staff 9 (Med Tech) was hired on 09/15/2021 and administered medications to residents. There was no documented evidence of Staff 9's demonstrated competency in medication administration until requested by the survey team on 04/23/24. * Staff 8 (Med Tech/Caregiver) was hired on 01/08/24 and provided personal care to residents on the MCC independently. Staff 8 did not document demonstrated competency in providing care until 04/09/24. The requirement to maintain written documentation of training completed by each employee, to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing before working independently and/or administering medications to residents was discussed with Staff 1 (ED) and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to maintain documentation regarding each direct care staff's demonstrated competency and maintain written documentation of all training's completed by each employee. Findings include, but are not limited to: During a review of staff training records on 04/23/24 and 04/24/24, Staff 4 (Business Office Coordinator) was unable to provide documented evidence that sampled staff administering medications and providing personal care had completed pre-service dementia training and demonstrated competency in all duties they were assigned before working independently with residents including: * Staff 9 (Med Tech) was hired on 09/15/2021 and administered medications to residents. There was no documented evidence of Staff 9's demonstrated competency in medication administration until requested by the survey team on 04/23/24. * Staff 8 (Med Tech/Caregiver) was hired on 01/08/24 and provided personal care to residents on the MCC independently. Staff 8 did not document demonstrated competency in providing care until 04/09/24. The requirement to maintain written documentation of training completed by each employee, to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing before working independently and/or administering medications to residents was discussed with Staff 1 (ED) and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills every other month, ensure a complete written fire drill record was kept and provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire drill and fire and life safety training records were reviewed with Staff 3 (Maintenance Technician) and Staff 1 (ED) on 04/23/24 at 11:00 am. The following were identified: a. The facility had not provided staff with life safety instruction at least every other month; b. The fire drill records from 10/01/24 to 4/22/24 failed to document one or more of the following required components: * Location of the simulated fire; * Evidence alternate routes were used; and * Problems encountered and comments relating to residents who resisted or failed to participate in the drills. The requirements for providing and documenting fire drills and fire and life safety training for staff was discussed with Staff 1 and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills every other month, ensure a complete written fire drill record was kept and provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire drill and fire and life safety training records were reviewed with Staff 3 (Maintenance Technician) and Staff 1 (ED) on 04/23/24 at 11:00 am. The following were identified: a. The facility had not provided staff with life safety instruction at least every other month; b. The fire drill records from 10/01/24 to 4/22/24 failed to document one or more of the following required components: * Location of the simulated fire; * Evidence alternate routes were used; and * Problems encountered and comments relating to residents who resisted or failed to participate in the drills. The requirements for providing and documenting fire drills and fire and life safety training for staff was discussed with Staff 1 and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings. I. Fire drills will be completed every month on rotating shifts and documented with the neccesary information such as location of the fire, alternate routes, and any problems encountered. Maintenance Technician received additional training on fire drills and accompanying documentation including the requirement to identify the location of the simulated fire and any problems that were encountered during the drill. 2. Maintenance Technician will receive additional training on documentation regarding the location of the simulated fire and any problems that were encountered during the drill.  Staff will receive additional training on fire drill routes and options for any residents who resisted or failed to participate in the drill. 3. The fire drill reports will be reviewed by the ED or designee each month. 4. Responsible Parties: ED, Maintenance Technician or designee. I. Fire drills will be completed every month on rotating shifts and documented with the neccesary information such as location of the fire, alternate routes, and any problems encountered. Maintenance Technician received additional training on fire drills and accompanying documentation including the requirement to identify the location of the simulated fire and any problems that were encountered during the drill. 2. Maintenance Technician will receive additional training on documentation regarding the location of the simulated fire and any problems that were encountered during the drill.  Staff will receive additional training on fire drill routes and options for any residents who resisted or failed to participate in the drill. 3. The fire drill reports will be reviewed by the ED or designee each month. 4. Responsible Parties: ED, Maintenance Technician or designee. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and at least annually thereafter. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 04/23/24. The facility lacked documented evidence residents were instructed on general safety procedures, evacuation methods, and responsibilities within 24 hours of admission and annually. The need for residents to be instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (ED) and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and at least annually thereafter. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 04/23/24. The facility lacked documented evidence residents were instructed on general safety procedures, evacuation methods, and responsibilities within 24 hours of admission and annually. The need for residents to be instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (ED) and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C 231, C 270, C 280, C 295, C 361, and Z 163. Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C 231, C 270, C 280, C 295, C 361, and Z 163.”

“Based on observation and interview, it was determined the facility failed to ensure there was locked storage for all poisons, chemicals, and other toxic materials. Findings include, but are not limited to: Observations of the facility on 04/22/24 identified the following: * The beauty shop directly off the Towne Square activity area was unlocked and accessible to residents. In the beauty shop an unlocked drawer contained sharp scissors, wood glue and other toxic materials. * The Clare unit activity kitchen had unlocked clear glass cabinets with dermal wound cleanser, disinfectant wipes, and disinfectant spray. * The Bridge unit activity kitchen had unlocked clear glass cabinets with disinfectant spray and wipes. The need to use locked storage for all poisons, chemicals, and other toxic materials was discussed with Staff 1 (ED) and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure there was locked storage for all poisons, chemicals, and other toxic materials. Findings include, but are not limited to: Observations of the facility on 04/22/24 identified the following: * The beauty shop directly off the Towne Square activity area was unlocked and accessible to residents. In the beauty shop an unlocked drawer contained sharp scissors, wood glue and other toxic materials. * The Clare unit activity kitchen had unlocked clear glass cabinets with dermal wound cleanser, disinfectant wipes, and disinfectant spray. * The Bridge unit activity kitchen had unlocked clear glass cabinets with disinfectant spray and wipes. The need to use locked storage for all poisons, chemicals, and other toxic materials was discussed with Staff 1 (ED) and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure interior surfaces and equipment necessary for the health, safety, and comfort of residents were kept clean and in good repair. Findings include, but are not limited to: The interior of the building was toured on 04/22/24 and again on 04/23/24. The following areas were observed to need cleaning and/or repair: * The resident use bathroom directly off the Towne Square activity area: a. A bucket was placed underneath the toilet water inlet to contain a leaking connection. b. Ceramic sink base mounted to the wall was dislodged and loosely hanging. * Persistent urine odors were noted on 04/22/24 and 04/23/24 outside the Bridge unit laundry room; * Carpet in both the Clare and Bridge units television rooms had red carpet stains in front of the chairs; * On 04/24/24 the Bridge unit laundry room had a washing machine water drain pipe connected with black duct tape, it was observed to leak water onto the floor of the laundry room. * Interior courtyards in both Clare and Bridge units had wood shingles and siding detached from the exterior walls, and multiple areas of rotted wood in the window and door frames, exposing the underlayment. On 04/24/24 the areas were shown to and discussed with Staff 3 (Maintenance Technician), Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure interior surfaces and equipment necessary for the health, safety, and comfort of residents were kept clean and in good repair. Findings include, but are not limited to: The interior of the building was toured on 04/22/24 and again on 04/23/24. The following areas were observed to need cleaning and/or repair: * The resident use bathroom directly off the Towne Square activity area: a. A bucket was placed underneath the toilet water inlet to contain a leaking connection. b. Ceramic sink base mounted to the wall was dislodged and loosely hanging. * Persistent urine odors were noted on 04/22/24 and 04/23/24 outside the Bridge unit laundry room; * Carpet in both the Clare and Bridge units television rooms had red carpet stains in front of the chairs; * On 04/24/24 the Bridge unit laundry room had a washing machine water drain pipe connected with black duct tape, it was observed to leak water onto the floor of the laundry room. * Interior courtyards in both Clare and Bridge units had wood shingles and siding detached from the exterior walls, and multiple areas of rotted wood in the window and door frames, exposing the underlayment. On 04/24/24 the areas were shown to and discussed with Staff 3 (Maintenance Technician), Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.”

“During the survey, concerns were identified in the following area and the facility was provided with technical assistance: H 1511 Individual Rights Settings: OAR 411-004-0020 (1)(d) (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. During the survey, concerns were identified in the following area and the facility was provided with technical assistance: H 1511 Individual Rights Settings: OAR 411-004-0020 (1)(d) (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting.”

“During the survey, concerns were identified in the following area and the facility was provided with technical assistance: H 1515: Physical Setting: Individual Accessible OAR411-004-0020(2)(b) (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. During the survey, concerns were identified in the following area and the facility was provided with technical assistance: H 1515: Physical Setting: Individual Accessible OAR411-004-0020(2)(b) (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. There are no detail notes for this visit.”

“During the survey, concerns were identified in the following area and the facility was provided with technical assistance: H 1518 Individual Door Locks: Key Access OAR 4110004-0020(2)(e) (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. During the survey, concerns were identified in the following area and the facility was provided with technical assistance: H 1518 Individual Door Locks: Key Access OAR 4110004-0020(2)(e) (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. There are no detail notes for this visit.”

“During the survey, concerns were identified in the following area and the facility was provided with technical assistance: H 1521 Individual Vistors: Any Time OAR 411-004-0020 (2)(h) (h) Each individual may have visitors of his or her choosing at any time. During the survey, concerns were identified in the following area and the facility was provided with technical assistance: H 1521 Individual Vistors: Any Time OAR 411-004-0020 (2)(h) (h) Each individual may have visitors of his or her choosing at any time. There are no detail notes for this visit.”

“Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities.  Findings include, but are not limited to: Refer to: C 260, C 270, C 280, C 295 and C 330. 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 260, C 270, C 280, C 295 and C 330. Refer to the plans of correction for C260, C270, C280, C295, C330 Refer to the plans of correction for C260, C270, C280, C295, C330 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 243, C 270, C 280, and C 295. 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 243, C 270, C 280, and C 295. Refer to the plans of corrections submitted for C243, C270, C280, C295 Refer to the plans of corrections submitted for C243, C270, C280, C295 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 nutritional plan for each resident was developed and included in the resident's service plan for 1 of 3 sampled residents (# 5) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to: Resident 5 moved into the memory care community in 03/2023 with diagnoses including Alzheimer's disease with late onset and dementia. The resident's clinical record was reviewed, interviews with care staff and meal observations were conducted during the survey and the following was identified: * The service plan offered the following staff instruction: "will want coffee with [his/her] meals ...will have at least three six oz [ounce] glasses of fluids with most meals." There was no additional information regarding resident specific food or fluid preferences. * The MAR dated 04/01/24 through 04/21/24 instructed staff to provide a Mighty Shake with each snack twice daily and give with any meal that [s/he] eats less than 50% of the meal, twice daily. The MAR indicated staff were only giving the Mighty Shake twice daily at the scheduled times of 10:00 am and 2:00 pm. On 04/22/24 at 11:44 am, the resident was served a plate of mashed potatoes and gravy, chopped chicken, a dinner roll, a small bowl of soup, small bowl of mandarin oranges, a bowl of cake and one glass of apple juice. * The resident pushed the plate of food away into the middle of the table where it remained for the duration of the meal; * The resident used a spoon and ate 100% of the soup, mandarin oranges and cake that was served in a bowl.; * The resident drank half the glass of apple juice; * Surveyor observed the resident had eaten 0% of the mashed potatoes and gravy, chopped chicken, and dinner roll that was served on the plate; and * There was no coffee provided during the meal. During the breakfast meal observation on 04/23/24 at 8:24 am, the resident was observed with his/her head bowed down and arms crossed at the dining room table. S/he had a plate of scrambled eggs, bacon, canned fruit, half of an english muffin and one glass of apple juice. There was a fork laying on the plate and it appeared that s/he had eaten a couple bites of egg and fruit, approximately 15 %. The bacon and muffin were untouched. There was no coffee provided, there was no observation of cueing the resident to eat or assistance to help the resident eat and a mighty shake wasn't given to the resident. During the lunch meal observation on 04/23/24 at 11:45 am, the resident was served a plate of mashed potatoes and gravy, a slice of meat loaf, green beans, a dinner roll and one glass of red colored juice. There was no coffee provided. At 12:06 pm, Staff 16 chopped the resident's meat loaf into 4 pieces, stating "ok, lets eat [resident name]" and then placed the fork on the plate and walked away from the resident. The resident crossed his/her arms and bowed his/her head. At 12:10 pm, Staff 16 approached the resident and stated "are you falling asleep, are you tired? Come on take a bite" and then walked away. No bite was taken, and the resident again crossed his/her arms and bowed his/her head. At 12:25 pm, Staff 16 physically assisted and offered a bite of meat loaf. The resident took the bite. Then the caregiver stated, "you don't like it, what do you like, do you like the bread, the beans, the mashed potatoes, PBJ, do you like that? The resident replied, "no." Staff 16 stated, "ok, I will take it for you" and removed the plate at 12:29 pm. During an interview on 04/23/24 at 2:45 pm, Staff 26 (CG) reported the resident "doesn't really eat much at dinner time. I try to offer him/her another snack or extra dessert. We are not asked to monitor snacks, meals or fluids. We do for some [residents], but not [him/her]." During an interview on 04/24/24 at 1:07 pm, Staff 27 (CG) reported the resident ate approximately 45 % of the lunch meal, had a pudding for dessert and was given a Boost, however she could not recall how much of the Boost the resident had consumed. There was no documented evidence the facility developed a daily meal program for nutrition and hydration that was based upon the resident's preferences, ability to eat independently or need for adaptive utensils in order to maintain eating ability. Additionally, the facility failed to ensure an individualized nutrition plan was developed and documented in the resident's service plan. The need to develop individualized nutritional plans addressing residents' nutrition and hydration preferences and needs was discussed with Staff 1 (ED), Staff 2 (RN, Health and Wellness Director), and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutritional plan for each resident was developed and included in the resident's service plan for 1 of 3 sampled residents (# 5) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to: Resident 5 moved into the memory care community in 03/2023 with diagnoses including Alzheimer's disease with late onset and dementia. The resident's clinical record was reviewed, interviews with care staff and meal observations were conducted during the survey and the following was identified: * The service plan offered the following staff instruction: "will want coffee with [his/her] meals ...will have at least three six oz [ounce] glasses of fluids with most meals." There was no additional information regarding resident specific food or fluid preferences. * The MAR dated 04/01/24 through 04/21/24 instructed staff to provide a Mighty Shake with each snack twice daily and give with any meal that [s/he] eats less than 50% of the meal, twice daily. The MAR indicated staff were only giving the Mighty Shake twice daily at the scheduled times of 10:00 am and 2:00 pm. On 04/22/24 at 11:44 am, the resident was served a plate of mashed potatoes and gravy, chopped chicken, a dinner roll, a small bowl of soup, small bowl of mandarin oranges, a bowl of cake and one glass of apple juice. * The resident pushed the plate of food away into the middle of the table where it remained for the duration of the meal; * The resident used a spoon and ate 100% of the soup, mandarin oranges and cake that was served in a bowl.; * The resident drank half the glass of apple juice; * Surveyor observed the resident had eaten 0% of the mashed potatoes and gravy, chopped chicken, and dinner roll that was served on the plate; and * There was no coffee provided during the meal. During the breakfast meal observation on 04/23/24 at 8:24 am, the resident was observed with his/her head bowed down and arms crossed at the dining room table. S/he had a plate of scrambled eggs, bacon, canned fruit, half of an english muffin and one glass of apple juice. There was a fork laying on the plate and it appeared that s/he had eaten a couple bites of egg and fruit, approximately 15 %. The bacon and muffin were untouched. There was no coffee provided, there was no observation of cueing the resident to eat or assistance to help the resident eat and a mighty shake wasn't given to the resident. During the lunch meal observation on 04/23/24 at 11:45 am, the resident was served a plate of mashed potatoes and gravy, a slice of meat loaf, green beans, a dinner roll and one glass of red colored juice. There was no coffee provided. At 12:06 pm, Staff 16 chopped the resident's meat loaf into 4 pieces, stating "ok, lets eat [resident name]" and then placed the fork on the plate and walked away from the resident. The resident crossed his/her arms and bowed his/her head. At 12:10 pm, Staff 16 approached the resident and stated "are you falling asleep, are you tired? Come on take a bite" and then walked away. No bite was taken, and the resident again cross”

“Based on observation, interview, and record review, it was determined the facility failed to develop individualized activity plans for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose evaluations and service plans were reviewed. Findings include, but are not limited to: Observations and interviews were completed between 04/22/24 and 04/24/24. Service plans and evaluations were reviewed for Residents 1, 2, 3, 4, 5 and 6. The following were identified: During an interview on 04/23/24 at 1:35 pm, Staff 1 (ED) reported the facility had a "Life Story" that was completed when the resident moved into the facility however; the information obtained on the "Life Story" did not meet regulation. There was no documented evidence activity evaluations were completed that reflected each resident's activity preferences and needs and individualized activity plans were developed based on the residents' activity evaluation. The need to ensure the facility developed individualized activity plans for each resident was discussed with Staff 1 and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to develop individualized activity plans for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose evaluations and service plans were reviewed. Findings include, but are not limited to: Observations and interviews were completed between 04/22/24 and 04/24/24. Service plans and evaluations were reviewed for Residents 1, 2, 3, 4, 5 and 6. The following were identified: During an interview on 04/23/24 at 1:35 pm, Staff 1 (ED) reported the facility had a "Life Story" that was completed when the resident moved into the facility however; the information obtained on the "Life Story" did not meet regulation. There was no documented evidence activity evaluations were completed that reflected each resident's activity preferences and needs and individualized activity plans were developed based on the residents' activity evaluation. The need to ensure the facility developed individualized activity plans for each resident was discussed with Staff 1 and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure behavioral symptoms, which negatively impacted the resident and others in the MCC, were evaluated and included in the service plan, for 1 of 2 sampled residents (# 3) whose behavioral issues were reviewed. Findings include but are not limited to: Resident 3 moved into the  memory care community in 09/2023 with diagnoses including dementia. During the acuity interview on 04/22/24, the resident was identified to have verbal aggression and received as needed medication to address the aggression. On 04/22/24, the resident was observed to push a female resident's wheelchair to the dining room for lunch. An interview, 04/23/24 at 12:45 pm, Staff 14 (CG) and Staff 16 (CG) reported Resident 3 tended to be upset when male residents were present around female residents. The resident was noted to be very protective when female residents were present. They further stated the resident could be agitated with showering and refused shower assistance. Review of the resident's clinical records indicated the resident was involved in a resident to resident altercation on 03/29/24 that the resident was standing over another resident "who was laying on [his/her] back...". Further record review including the 04/01/24 through 04/22/24 MAR, noted the resident refused showers on seven occasions. There was no documented evidence the facility evaluated Resident 3's behaviors which could negativity impact other residents. Also, there was no specific interventions and instructions in the service plan to guide caregiving staff in responding to Resident 3's behavioral symptoms. On 04/24/24, the above findings were shared with Staff 1 (ED), Staff 2 (RN, Health and Wellness Director), Staff 5 (District Director of Operations) and Staff 22 (RN, District Director of Clinical Operations) and discussed to ensure behavioral symptoms which negatively impact the resident and others were evaluated and included in the service plan. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure behavioral symptoms, which negatively impacted the resident and others in the MCC, were evaluated and included in the service plan, for 1 of 2 sampled residents (# 3) whose behavioral issues were reviewed. Findings include but are not limited to: Resident 3 moved into the  memory care community in 09/2023 with diagnoses including dementia. During the acuity interview on 04/22/24, the resident was identified to have verbal aggression and received as needed medication to address the aggression. On 04/22/24, the resident was observed to push a female resident's wheelchair to the dining room for lunch. An interview, 04/23/24 at 12:45 pm, Staff 14 (CG) and Staff 16 (CG) reported Resident 3 tended to be upset when male residents were present around female residents. The resident was noted to be very protective when female residents were present. They further stated the resident could be agitated with showering and refused shower assistance. Review of the resident's clinical records indicated the resident was involved in a resident to resident altercation on 03/29/24 that the resident was standing over another resident "who was laying on [his/her] back...". Further record review including the 04/01/24 through 04/22/24 MAR, noted the resident refused showers on seven occasions. There was no documented evidence the facility evaluated Resident 3's behaviors which could negativity impact other residents. Also, there was no specific interventions and instructions in the service plan to guide caregiving staff in responding to Resident 3's behavioral symptoms. On 04/24/24, the above findings were shared with Staff 1 (ED), Staff 2 (RN, Health and Wellness Director), Staff 5 (District Director of Operations) and Staff 22 (RN, District Director of Clinical Operations) and discussed to ensure behavioral symptoms which negatively impact the resident and others were evaluated and included in the service plan. They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure residents had access to an enclosed, secured outdoor area. Findings include, but are not limited to: Observations of the Clare and Bridge memory care units, from 04/22/24 through 04/23/24, revealed interior courtyard doors were locked, preventing residents from entering and exiting without staff assistance. There were no observations of inclement weather during that time. On 04/24/24 the need to provide access to secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings and stated they would unlock the doors from dawn to dusk except during severe weather. Based on observation and interview, it was determined the facility failed to ensure residents had access to an enclosed, secured outdoor area. Findings include, but are not limited to: Observations of the Clare and Bridge memory care units, from 04/22/24 through 04/23/24, revealed interior courtyard doors were locked, preventing residents from entering and exiting without staff assistance. There were no observations of inclement weather during that time. On 04/24/24 the need to provide access to secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings and stated they would unlock the doors from dawn to dusk except during severe weather.”

“Based on observation and interview, it was determined the memory care community failed to ensure a keyed lock was not placed between residents and the emergency exit, and the outside perimeter fencing allowed for egress in the event of an emergency. Findings include, but are not limited to: The facility's interior and outdoor areas were toured on 04/22/24. The facility was divided into two units, Clare and Bridge, which had the same layout and features.  Both unit's emergency exit to the outdoors was through two doors leading to a fenced outdoor area. Both emergency exit doors on both units were observed with keyed locks.  The outdoor areas each had one emergency exit, which were secured with  combination padlocks. In interview with Staff 1 (ED) and Staff 3 (Maintenance Technician) on 04/22/24, they confirmed the exit doors that were locked were the designated emergency exits, could only be opened with a key, and the outdoor areas only exit were the gates locked with padlocks. The requirement for memory care communities to not have entrance and exit doors that are closed with non-electronic keyed locks were discussed with Staff 1 and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings and stated the keyed and combination locks would be immediately removed leaving only electronic locks that released in case of an emergency. Based on observation and interview, it was determined the memory care community failed to ensure a keyed lock was not placed between residents and the emergency exit, and the outside perimeter fencing allowed for egress in the event of an emergency. Findings include, but are not limited to: The facility's interior and outdoor areas were toured on 04/22/24. The facility was divided into two units, Clare and Bridge, which had the same layout and features.  Both unit's emergency exit to the outdoors was through two doors leading to a fenced outdoor area. Both emergency exit doors on both units were observed with keyed locks.  The outdoor areas each had one emergency exit, which were secured with  combination padlocks. In interview with Staff 1 (ED) and Staff 3 (Maintenance Technician) on 04/22/24, they confirmed the exit doors that were locked were the designated emergency exits, could only be opened with a key, and the outdoor areas only exit were the gates locked with padlocks. The requirement for memory care communities to not have entrance and exit doors that are closed with non-electronic keyed locks were discussed with Staff 1 and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings and stated the keyed and combination locks would be immediately removed leaving only electronic locks that released in case of an emergency.”

“The findings of the kitchen inspection, conducted 04/04/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the kitchen inspection, conducted 04/04/24, 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.”