Sherwood Pines Residential Care.

“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 the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations of the main kitchen and food storage areas on 01/07/26 at 11:15 am through 1:00 pm revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Interior of drawers storing clean equipment; * Interior of cabinets storing food and/or equipment; * Top of reach-in refrigerators/freezers; and * Sponge used to clean dishes. b. The following areas were found in need of repair: * Multiple cabinets observed with edges and spots noted with porous wood exposed; and * Section of caulking behind the sink with damage and in need of replacement. c. Multiple items in reach-in refrigerators found with food items not dated when opened. d. Multiple potentially hazardous food items found in refrigerators that were past the manufacturer’s use by date and should have been discarded. e. Resident-specific food items were stored in refrigerators without resident identifiers or open/prepared dates. f. Whole shell egg cartons stored above ready to eat foods (milk cartons) posing a risk for cross contamination. g. Different raw meat products (beef/pork/ground meats) were stored in the same bin/storage space causing potential for cross contamination of the packages. h. A bag of shredded cheese was found stored open, exposing ready to eat food to possible contamination. i. Reach-in refrigerator near entry to kitchen did not have an internal thermometer to accurately monitor cold food storage temperatures. Staff were relying on the display temperature for monitoring. The temperature displayed was the temperature setting, not the internal temperature of the refrigerator. j. Staff were taking and recording the temperature of the hot food entrées only. Facility did not have a system for monitoring side dish or cold food temperatures for resident foods. Food temperature logs were reviewed, and multiple days were missing. k. Multiple food items were found stored in the pantry on the floor. l. A baking pan was noted to be heavily worn with large amount of baked on carbon debris and in need of replacement. A non-stick pan was noted to have multiple scratches where protective coating was worn/removed/chipped and in need of replacement. An ice cream scoop was worn with protective coating removed and needed replaced. Surveyor toured areas with Staff 2 (Cook/RCC) who acknowledged areas in need of correction. On 01/13/26 at approximately 1:00 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Administrator), and she acknowledged the areas in need of correction. OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by:”

“Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. 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, conducted during a site visit on 05/30/24, it was confirmed the facility failed to ensure the implementation of services for 3 of 4 sampled residents (#1's, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to: Compliance Specialist (CS) observed the following on 05/30/24; · Residents 3 and 4 were in the dining room eating lunch at 12:38pm · At 5:50 pm Resident 1, Resident 3, and Resident 4 were up in the dining room eating dinner, · 5 staff were present in the facility and supervising dinner service, · Staff 2 (CG/Shower aide) was getting Resident 2's dinner cooled down to assist with feeding in his/her room. In an interview on 05/30/24, Staff 1 (ED) stated the following: · Showers were documented in the EMAR, · Nobody was auditing the showers lately to make sure they were getting documented, · The bath aide was in from 12pm-8pm to do showers, · Staff were feeding the residents, · There was one resident that got fed in bed and another 3 residents that were supervised. In an interview on 05/30/24, Staff 3 (CG/MT) stated the following: · We supervised three of the residents in the dining room, · Resident 2 was fed in his/her room, · "They always get fed. No concerns about them not getting fed", · " Showers get done when we have a shower aide [here]". In an interview with Resident 2 on 05/30/24, s/he stated the following: · "I get three meals a day if I want them" , · "They always help me get up to eat my meals", · "I had breakfast this morning" A review of Resident 1, Resident 2, Resident 3, and Resident 4's service plans and shower sheets for 05/01/24 through 05/31/24, indicated the following: * All three residents' service plans show baths needed at least twice per week, * Resident 1's only documented showers were on 05/18/24 and 05/25/24, * Resident 2's only documented showers were on 05/06/24, 05/23/24, and 05/27/24, * Resident 4's only documented showers were on 05/18/24 and 05/25/24, * Residents 1, 2, and 4 were not getting showers twice per week for the month of May 2024. The findings were reviewed with and acknowledged by Staff 1 on 05/30/24. It was confirmed the facility failed to ensure the implementation of services. Plan of correction: Facility is considering moving the shower aide shift from 7am-3pm instead of 12pm-8pm. Frequent auditing will be done by management to ensure that staff are completing and documenting showers or any refusals. Based on observation, interview, and record review, conducted during a site visit on 05/30/24, it was confirmed the facility failed to ensure the implementation of services for 3 of 4 sampled residents (#1's, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to: Compliance Specialist (CS) observed the following on 05/30/24; · Residents 3 and 4 were in the dining room eating lunch at 12:38pm · At 5:50 pm Resident 1, Resident 3, and Resident 4 were up in the dining room eating dinner, · 5 staff were present in the facility and supervising dinner service, · Staff 2 (CG/Shower aide) was getting Resident 2's dinner cooled down to assist with feeding in his/her room. In an interview on 05/30/24, Staff 1 (ED) stated the following: · Showers were documented in the EMAR, · Nobody was auditing the showers lately to make sure they were getting documented, · The bath aide was in from 12pm-8pm to do showers, · Staff were feeding the residents, · There was one resident that got fed in bed and another 3 residents that were supervised. In an interview on 05/30/24, Staff 3 (CG/MT) stated the following: · We supervised three of the residents in the dining room, · Resident 2 was fed in his/her room, · "They always get fed. No concerns about them not getting fed", · " Showers get done when we have a shower aide [here]". In an interview with Resident 2 on 05/30/24, s/he stated the following: · "I get three meals a day if I want them" , · "They always help me get up to eat my meals", · "I had breakfast this morning" A review of Resident 1, Resident 2, Resident 3, and Resident 4's service plans and shower sheets for 05/01/24 through 05/31/24, indicated the following: * All three residents' service plans show baths needed at least twice per week, * Resident 1's only documented showers were on 05/18/24 and 05/25/24, * Resident 2's only documented showers were on 05/06/24, 05/23/24, and 05/27/24, * Resident 4's only documented showers were on 05/18/24 and 05/25/24, * Residents 1, 2, and 4 were not getting showers twice per week for the month of May 2024. The findings were reviewed with and acknowledged by Staff 1 on 05/30/24. It was confirmed the facility failed to ensure the implementation of services. Plan of correction: Facility is considering moving the shower aide shift from 7am-3pm instead of 12pm-8pm. Frequent auditing will be done by management to ensure that staff are completing and documenting showers or any refusals.”

“Based on observation, interview and record review, conducted during a site visit on 05/30/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: In an interview on 05/30/24, Staff 1 (Executive Director) stated the current census was 15 residents. Resident 5 moved in two days ago, and there was a resident that passed away, but the ABST had not been updated yet. Staff 1 stated staff were universal workers with additional tasks of cooking, serving food, housekeeping, activities, etc. A review of the facility's ABST and resident roster on 05/30/24, indicated the following: * There was 15 residents listed on the roster. * Resident 5 who moved in on 05/28/24 was not listed on the ABST. * On day shifts, 3.35 caregivers were needed; for swing shifts 3.19 caregivers were needed; and for night shift, 1.25 caregivers were needed. * Ten residents' ABST profiles had not been updated since 10/04/23. A review of the facility's posted staffing plan indicated the following: * Day shift 7am-3:15pm: one CG,  one MT; * Swing shift 3pm-11:15pm: one CG, one MT; * Noc shift 11pm-7:15am: one CG, one MT; * Activities 10am-6pm; and * Bath aide 12pm-8pm. A review of the facility's staff schedules, dated April 2024 and May 2024,  indicated the facility was staffing per their posted staffing plan. In an interview on 05/30/24, Staff 4 (CG/Activities) stated: "I do activities and help out wherever needs help". Compliance Specialist observed the following: * Day and swing shifts had a MT, a CG, an activities staff member, and a shower aide working. * At 12:04pm, the Staff 4 (Activities) was assisting with other caregiving duties such as transfering and assisting residents to the dining room for lunch and assisting with eating. * At 5:50pm, the Staff 2 (shower aide) was assisting with meals/feeding. A review of Resident 1, 2, and 4s'  service plans, dated 03/13/24, 03/26/24, 04/18/24, respectively, and shower sheets from 05/01/24-05/31/24, indicated the following: * All three residents' service plans show baths needed at least twice per week, * Resident 1's only documented showers were on 05/18/24 and 05/25/24, * Resident 2's only documented showers were on 05/06/24, 05/23/24, and 05/27/24, * Resident 4's only documented showers were on 05/18/24 and 05/25/24, * Residents 1, 2, and 4 were not getting showers twice per week for the month of May 2024. On 05/30/24, findings were reviewed with and acknowledged by Staff 1. It was confirmed the facility failed to fully implement and update an ABST. Based on observation, interview and record review, conducted during a site visit on 05/30/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: In an interview on 05/30/24, Staff 1 (Executive Director) stated the current census was 15 residents. Resident 5 moved in two days ago, and there was a resident that passed away, but the ABST had not been updated yet. Staff 1 stated staff were universal workers with additional tasks of cooking, serving food, housekeeping, activities, etc. A review of the facility's ABST and resident roster on 05/30/24, indicated the following: * There was 15 residents listed on the roster. * Resident 5 who moved in on 05/28/24 was not listed on the ABST. * On day shifts, 3.35 caregivers were needed; for swing shifts 3.19 caregivers were needed; and for night shift, 1.25 caregivers were needed. * Ten residents' ABST profiles had not been updated since 10/04/23. A review of the facility's posted staffing plan indicated the following: * Day shift 7am-3:15pm: one CG,  one MT; * Swing shift 3pm-11:15pm: one CG, one MT; * Noc shift 11pm-7:15am: one CG, one MT; * Activities 10am-6pm; and * Bath aide 12pm-8pm. A review of the facility's staff schedules, dated April 2024 and May 2024,  indicated the facility was staffing per their posted staffing plan. In an interview on 05/30/24, Staff 4 (CG/Activities) stated: "I do activities and help out wherever needs help". Compliance Specialist observed the following: * Day and swing shifts had a MT, a CG, an activities staff member, and a shower aide working. * At 12:04pm, the Staff 4 (Activities) was assisting with other caregiving duties such as transfering and assisting residents to the dining room for lunch and assisting with eating. * At 5:50pm, the Staff 2 (shower aide) was assisting with meals/feeding. A review of Resident 1, 2, and 4s'  service plans, dated 03/13/24, 03/26/24, 04/18/24, respectively, and shower sheets from 05/01/24-05/31/24, indicated the following: * All three residents' service plans show baths needed at least twice per week, * Resident 1's only documented showers were on 05/18/24 and 05/25/24, * Resident 2's only documented showers were on 05/06/24, 05/23/24, and 05/27/24, * Resident 4's only documented showers were on 05/18/24 and 05/25/24, * Residents 1, 2, and 4 were not getting showers twice per week for the month of May 2024. On 05/30/24, findings were reviewed with and acknowledged by Staff 1. It was confirmed the facility failed to fully implement and update an ABST.”

“The findings of the kitchen inspection, conducted 02/07/24, 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 02/07/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.”

“Based on observation, interview and record review, 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 280, and C 290. 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 280, and C 290. See Plan of Corrections listed above for C 260, C 280 C 290. See Plan of Corrections listed above for C 260, C 280 C 290. There are no detail notes for this visit.”

“The findings of the re-licensure survey, conducted 10/03/23 through 10/05/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the re-licensure survey, conducted 10/03/23 through 10/05/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for 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 revisit to the re-licensure survey of 10/05/23, conducted 02/06/24, 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 and OARs 411 Division 57 for Memory Care Communities. The findings of the revisit to the re-licensure survey of 10/05/23, conducted 02/06/24, 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 and OARs 411 Division 57 for Memory Care Communities.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff for 1 of 2 sampled residents (#1). Findings include, but are not limited to: Resident 1 was admitted to the memory care community in May of 2023 with diagnoses including vascular dementia with behavioral disturbance. Observations of the resident, interviews with staff between 10/03/23 and 10/05/23, review of the service plan, dated 09/28/23, and charting notes, dated 07/03/23 through 10/03/23, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Physically aggressive behaviors and interventions; and * Two person assist with toileting, incontinence care, and showering. The need to ensure service plans reflected the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff for 1 of 2 sampled residents (#1). Findings include, but are not limited to: Resident 1 was admitted to the memory care community in May of 2023 with diagnoses including vascular dementia with behavioral disturbance. Observations of the resident, interviews with staff between 10/03/23 and 10/05/23, review of the service plan, dated 09/28/23, and charting notes, dated 07/03/23 through 10/03/23, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Physically aggressive behaviors and interventions; and * Two person assist with toileting, incontinence care, and showering. The need to ensure service plans reflected the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the findings. Template used for service plan has been updated to reflect issues with agitation and aggression during personal care, a new service plan has been developed reflecting his  needs during personal care if agitation and aggression is an issue and addresses how staff should respond in those instances. The template is used for all facility residents' service planning and will address any potential aggression and agitation concerns in personal care. These issues will be addressed with every service plan, for every resident, as specified by OAR. The service plan is updated and implemented by the Service Planning Team which includes the RN and Administrator and may also include the Back-Up Managers and care partners. Template used for service plan has been updated to reflect issues with agitation and aggression during personal care, a new service plan has been developed reflecting his  needs during personal care if agitation and aggression is an issue and addresses how staff should respond in those instances. The template is used for all facility residents' service planning and will address any potential aggression and agitation concerns in personal care. These issues will be addressed with every service plan, for every resident, as specified by OAR. The service plan is updated and implemented by the Service Planning Team which includes the RN and Administrator and may also include the Back-Up Managers and care partners. There are no detail notes for this visit.”

“Based on interview, observation, and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 2 sampled residents (#2) who experienced a significant change of condition. Findings include, but are not limited to: Resident 2 moved into the memory care community in July of 2023 with diagnoses including vascular dementia and mood disturbance. Review of the resident's monthly weight records from 08/02/23 through 09/26/23 showed the following: The resident experienced an 8.0 pound weight loss from 08/08/23 to 09/19/23, which constituted a 6% weight loss in one month. The resident weighed 132 pounds on 08/08/23 and 124 pounds on 09/19/23. In an interview with Staff 2 (Officer/RN) on 10/03/23, she reported she was not aware of the weight loss because she was on vacation. She stated she had not been informed of the weight loss upon return. A current weight and RN assessment was requested and provided on 10/4/23. The resident weighed 124.6 on 10/4/23 and was observed eating 100% of meals during the survey. Staff 2, Staff 6 (CG), and Staff 8 (CG), all reported Resident 2 had a good appetite except for the time period s/he had COVID, which coincided with the weight loss. On 10/05/23 the need to ensure the facility RN completed an assessment for all residents who experienced significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer). They acknowledged the findings. Based on interview, observation, and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 2 sampled residents (#2) who experienced a significant change of condition. Findings include, but are not limited to: Resident 2 moved into the memory care community in July of 2023 with diagnoses including vascular dementia and mood disturbance. Review of the resident's monthly weight records from 08/02/23 through 09/26/23 showed the following: The resident experienced an 8.0 pound weight loss from 08/08/23 to 09/19/23, which constituted a 6% weight loss in one month. The resident weighed 132 pounds on 08/08/23 and 124 pounds on 09/19/23. In an interview with Staff 2 (Officer/RN) on 10/03/23, she reported she was not aware of the weight loss because she was on vacation. She stated she had not been informed of the weight loss upon return. A current weight and RN assessment was requested and provided on 10/4/23. The resident weighed 124.6 on 10/4/23 and was observed eating 100% of meals during the survey. Staff 2, Staff 6 (CG), and Staff 8 (CG), all reported Resident 2 had a good appetite except for the time period s/he had COVID, which coincided with the weight loss. On 10/05/23 the need to ensure the facility RN completed an assessment for all residents who experienced significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer). They acknowledged the findings. ata will be analyzed monthly for changes in weight for each resident.  The Administrator and RN will work in conjuction to analyze and address changes in weight. At the beginning of each month they will review previous month's weights for changes in weight.  Weights reviewed will be previous 30 days, 90 days, and 6 month time span. An alert from the Facility Calendar will prompt a review of the monthly weights, as will a monthly task in the internal data system. This will be implemented and monitored by the Administrator and RN. Weight calculator template designed to help review weight changes. Providers will continue to be notified for any changes in weight per OAR guidelines. ata will be analyzed monthly for changes in weight for each resident.  The Administrator and RN will work in conjuction to analyze and address changes in weight. At the beginning of each month they will review previous month's weights for changes in weight.  Weights reviewed will be previous 30 days, 90 days, and 6 month time span. An alert from the Facility Calendar will prompt a review of the monthly weights, as will a monthly task in the internal data system. This will be implemented and monitored by the Administrator and RN. Weight calculator template designed to help review weight changes. Providers will continue to be notified for any changes in weight per OAR guidelines. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure activity evaluations addressed all required components and individualized activity plans were developed based on the activity evaluations for 2 of 2 sampled residents (#s 1 and 2) whose activity plans were reviewed. Findings include, but are not limited to: Resident 1 and 2's records were reviewed, and staff were interviewed. There was no documented evidence activity evaluations were completed which addressed the following required components: * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations needed to participate; and * Identification of activities for behavioral interventions. There was no documented evidence specific activity plans were developed which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities. The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure activity evaluations addressed all required components and individualized activity plans were developed based on the activity evaluations for 2 of 2 sampled residents (#s 1 and 2) whose activity plans were reviewed. Findings include, but are not limited to: Resident 1 and 2's records were reviewed, and staff were interviewed. There was no documented evidence activity evaluations were completed which addressed the following required components: * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations needed to participate; and * Identification of activities for behavioral interventions. There was no documented evidence specific activity plans were developed which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities. The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the findings. Life history form will now be required to be filled out by family prior to admission rather than as an optional form. This will aid RN/Administrator/Activity Director in addressing all required components and individualized activity plans per OAR requirements. Each resident will be evaluated using an established Activities Evaluation. This evaluation and an Activities Plan will be revised with each care plan update. The Administrator will monitor this process. Life history form will now be required to be filled out by family prior to admission rather than as an optional form. This will aid RN/Administrator/Activity Director in addressing all required components and individualized activity plans per OAR requirements. Each resident will be evaluated using an established Activities Evaluation. This evaluation and an Activities Plan will be revised with each care plan update. The Administrator will monitor this process. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure facility management or the licensed nurse were notified of the services provided by the outside provider and ensure recommendations made by outside providers were communicated to staff and the service plan adjusted for 1 of 2 sampled residents (#2) who received services from an outside provider. Findings include, but are not limited to: Resident 2 moved into the memory care community in July of 2023 with diagnoses including vascular dementia and mood disorder. During the acuity interview on 10/03/23, Resident 2 was identified as having recently received HH PT and speech therapy services. Staff 1 (Administrator) reported outside service provider notes were contained in the electronic chart notes and entered directly into the computer by outside providers. The resident's 07/31/23 through 10/03/23 progress notes were reviewed and identified the following: * A HH speech therapy note on 08/10/23 stated, "Supervise (intermittent ok) to cue swallow before talking, use slow rate, swallow bites/sips completely." * A HH PT note on 08/21/23 stated, "Recommend...PROM program to gently stretch hips and knees (30 second holds, 3-5 repetitions, 2 times per day)." There was no documentation these recommendations had been reviewed by facility management or the licensed nurse, had been communicated to staff, or the service plan updated. In an interview on 10/05/23, Staff 3 (Officer/RN) reported the process for informing the Administrator and RN's of outside provider visits involved a staff member logging onto the computer for the outside provider and designating the note as "Important," which would send the note to all the administrative staff. The HH notes on 08/10/23 and 08/21/23 were designated as "Low." Staff 3, Staff 2 (Officer/RN), and Staff 1 confirmed that they would not have seen these outside provider notes because of the designation. The need for the facility to coordinate on-site health services with outside service providers was discussed with Staff 1, Staff 2 , Staff 3, and Staff 4 (Officer) on 10/05/23. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure facility management or the licensed nurse were notified of the services provided by the outside provider and ensure recommendations made by outside providers were communicated to staff and the service plan adjusted for 1 of 2 sampled residents (#2) who received services from an outside provider. Findings include, but are not limited to: Resident 2 moved into the memory care community in July of 2023 with diagnoses including vascular dementia and mood disorder. During the acuity interview on 10/03/23, Resident 2 was identified as having recently received HH PT and speech therapy services. Staff 1 (Administrator) reported outside service provider notes were contained in the electronic chart notes and entered directly into the computer by outside providers. The resident's 07/31/23 through 10/03/23 progress notes were reviewed and identified the following: * A HH speech therapy note on 08/10/23 stated, "Supervise (intermittent ok) to cue swallow before talking, use slow rate, swallow bites/sips completely." * A HH PT note on 08/21/23 stated, "Recommend...PROM program to gently stretch hips and knees (30 second holds, 3-5 repetitions, 2 times per day)." There was no documentation these recommendations had been reviewed by facility management or the licensed nurse, had been communicated to staff, or the service plan updated. In an interview on 10/05/23, Staff 3 (Officer/RN) reported the process for informing the Administrator and RN's of outside provider visits involved a staff member logging onto the computer for the outside provider and designating the note as "Important," which would send the note to all the administrative staff. The HH notes on 08/10/23 and 08/21/23 were designated as "Low." Staff 3, Staff 2 (Officer/RN), and Staff 1 confirmed that they would not have seen these outside provider notes because of the designation. The need for the facility to coordinate on-site health services with outside service providers was discussed with Staff 1, Staff 2 , Staff 3, and Staff 4 (Officer) on 10/05/23. They acknowledged the findings. Training will take place during Staff meeting to ensure that all staff are marking progress notes as important prior to providing the outside provider the computer to document progress notes in our EMAR system. All outside provider notes will be reviewed by the Back-Up-Manager, Administrator, or Administrative Designee. They will review all outside provider notes at time of service to ensure they are properly recorded as 'Important'. The RN will review all outside provider notes and update service plans as necessary. On-going monitoring will happen by Administrator and RN. Process established and implemented for outside provider notes and posted in employee office. Training will take place during Staff meeting to ensure that all staff are marking progress notes as important prior to providing the outside provider the computer to document progress notes in our EMAR system. All outside provider notes will be reviewed by the Back-Up-Manager, Administrator, or Administrative Designee. They will review all outside provider notes at time of service to ensure they are properly recorded as 'Important'. The RN will review all outside provider notes and update service plans as necessary. On-going monitoring will happen by Administrator and RN. Process established and implemented for outside provider notes and posted in employee office. There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for residents. Findings include, but are not limited to: On 10/05/23 at 10:00 am, incontinence care for Resident 2 was observed to determine adherence to universal precautions for infection control. Staff 8 (CG) was observed to don gloves prior to the task. After performing incontinence care, Staff 8 touched the resident's clean brief, 4 bed pillows, bolster pillow, and clean sheets and comforter prior to doffing gloves. After doffing gloves, no hand hygiene was performed and Staff 8 touched wheelchair handles, Hoyer lift handles, inside and outside doorknobs to resident room, and doorknob leading into the laundry room. The need to ensure staff consistently used universal infection control precautions for the protection of residents was discussed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for residents. Findings include, but are not limited to: On 10/05/23 at 10:00 am, incontinence care for Resident 2 was observed to determine adherence to universal precautions for infection control. Staff 8 (CG) was observed to don gloves prior to the task. After performing incontinence care, Staff 8 touched the resident's clean brief, 4 bed pillows, bolster pillow, and clean sheets and comforter prior to doffing gloves. After doffing gloves, no hand hygiene was performed and Staff 8 touched wheelchair handles, Hoyer lift handles, inside and outside doorknobs to resident room, and doorknob leading into the laundry room. The need to ensure staff consistently used universal infection control precautions for the protection of residents was discussed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the findings. Established infection prevention protocols and sanitation measures were reviewed and additional training conducted at the monthly all Staff meeting on 10/18/2023. Infection and Prevention Control training has been re-issued to all staff to be completed by 11/18/2023. This will be included in our Quarterly Evaluation and Skills Checklist. This will implemented by the Administrator and monitored by the Administrator and Back-up Managers. Established infection prevention protocols and sanitation measures were reviewed and additional training conducted at the monthly all Staff meeting on 10/18/2023. Infection and Prevention Control training has been re-issued to all staff to be completed by 11/18/2023. This will be included in our Quarterly Evaluation and Skills Checklist. This will implemented by the Administrator and monitored by the Administrator and Back-up Managers. There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to ensure the grounds were free of litter and refuse, and the exterior pathways were made of hard and smooth material and maintained in good repair. Findings include, but are not limited to: Observations of the facility exterior on 10/04/23 identified the following: * Two broken chairs, a dresser, and multiple broken slats from the gazebo were inside the gazebo; and * The pathway around the gazebo had multiple cracks across the pathway, including drop-offs which created a potential tripping hazard for residents. These findings were reviewed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure the grounds were free of litter and refuse, and the exterior pathways were made of hard and smooth material and maintained in good repair. Findings include, but are not limited to: Observations of the facility exterior on 10/04/23 identified the following: * Two broken chairs, a dresser, and multiple broken slats from the gazebo were inside the gazebo; and * The pathway around the gazebo had multiple cracks across the pathway, including drop-offs which created a potential tripping hazard for residents. These findings were reviewed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the findings. 1.The upper area including the gazebo had a sign placed at the entrance of the area that states "Authorized Personell Only" and a chain to rope off the parking lot that states "Danger Do Not Enter." This area is for staff use only. All litter and dysfunctional furniture/appliances have been removed from the premises. Staff was informed of these changes at the all staff meeting on 11/18/2023. 2.The upper area including the gazebo had a sign placed at the entrance of the area that states "Authorized Personell Only" and a chain to rope off the parking lot that states "Danger Do Not Enter.". Staff was reminded of this at the all staff meeting on 11/18/2023. Administrator will do weekly walk-throughs of the outside premises to ensure there is no garbage or debris. 3. Administrator will do weekly walk-throughs to ensure there is no garbage or debris outside. 4. The Administrator will be responsible for ensuring all staff is aware that no residents are allowed in the upper areas referred to in POC. The Administrator will also be responsible for making sure there is no garbage or debris on the outdoor premises. 1.The upper area including the gazebo had a sign placed at the entrance of the area that states "Authorized Personell Only" and a chain to rope off the parking lot that states "Danger Do Not Enter." This area is for staff use only. All litter and dysfunctional furniture/appliances have been removed from the premises. Staff was informed of these changes at the all staff meeting on 11/18/2023. 2.The upper area including the gazebo had a sign placed at the entrance of the area that states "Authorized Personell Only" and a chain to rope off the parking lot that states "Danger Do Not Enter.". Staff was reminded of this at the all staff meeting on 11/18/2023. Administrator will do weekly walk-throughs of the outside premises to ensure there is no garbage or debris. 3. Administrator will do weekly walk-throughs to ensure there is no garbage or debris outside. 4. The Administrator will be responsible for ensuring all staff is aware that no residents are allowed in the upper areas referred to in POC. The Administrator will also be responsible for making sure there is no garbage or debris on the outdoor premises. There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were maintained in good repair. Findings include, but are not limited to: The interior of the facility was toured on 10/03/23. Door frames throughout the facility, including resident rooms and common use bathrooms, had scrapes and gouges, exposing bare wood. This finding was reviewed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the door frames needed repair. Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were maintained in good repair. Findings include, but are not limited to: The interior of the facility was toured on 10/03/23. Door frames throughout the facility, including resident rooms and common use bathrooms, had scrapes and gouges, exposing bare wood. This finding was reviewed with Staff 1 (Administrator), Staff 2 (Officer/RN), Staff 3 (Officer/RN), and Staff 4 (Officer) on 10/05/23. They acknowledged the door frames needed repair. All door frames with gouges will be repaired/replaced. This will be implemented by David Schill, owner and maintained quarterly. All door frames with gouges will be repaired/replaced. This will be implemented by David Schill, owner and maintained quarterly. There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to ensure the soiled linen room or area included a flushing rim clinical sink with a handheld rinsing device and a hand wash sink. Findings include, but are not limited to: During a tour of the laundry room on 10/03/23 it was observed there was only one standard sink in the laundry room. In an interview with Staff 7 (Caregiver), she reported that any waste matter on soiled linens, if applicable, was dumped into one of the shared facility bathroom toilets, then soaked in designated tubs in the laundry room sink. She stated they were washed separately from unsoiled linens, with a disinfectant added to the wash. It was observed the sink in the laundry room was also used for hand washing. The need to install a flushing rim sink in the soiled linen area was reviewed with Staff 1 (Administrator) and Staff 3 (Officer/RN) on 10/03/23. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure the soiled linen room or area included a flushing rim clinical sink with a handheld rinsing device and a hand wash sink. Findings include, but are not limited to: During a tour of the laundry room on 10/03/23 it was observed there was only one standard sink in the laundry room. In an interview with Staff 7 (Caregiver), she reported that any waste matter on soiled linens, if applicable, was dumped into one of the shared facility bathroom toilets, then soaked in designated tubs in the laundry room sink. She stated they were washed separately from unsoiled linens, with a disinfectant added to the wash. It was observed the sink in the laundry room was also used for hand washing. The need to install a flushing rim sink in the soiled linen area was reviewed with Staff 1 (Administrator) and Staff 3 (Officer/RN) on 10/03/23. They acknowledged the findings.”

“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 295, C 510, C 513 and C 530. 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 295, C 510, C 513 and C 530. See Plan of Corrections listed above for C 295, C 510, C 513 and C 530 See Plan of Corrections listed above for C 295, C 510, C 513 and C 530 There are no detail notes for this visit.”