Clatsop Care Memory Community.

“The findings of the re-licensure survey, conducted 04/01/24 through 04/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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. Tag numbers beginning with H refer to the Home and Community Based Services Rules OARs 411 Division 004. 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 04/01/24 through 04/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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. Tag numbers beginning with H refer to the Home and Community Based Services Rules OARs 411 Division 004. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the first re-visit to the re-licensure survey of 04/04/24, conducted 08/26/24 through 08/27/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the first re-visit to the re-licensure survey of 04/04/24, conducted 08/26/24 through 08/27/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the second re-visit to the re-licensure survey of 04/04/24, conducted on 10/18/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. The findings of the second re-visit to the re-licensure survey of 04/04/24, conducted on 10/18/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.”

“Based on interview and record review, it was determined the facility failed to promptly investigate incidents or injuries of unknown cause to rule-out abuse, document all required areas of an investigation, and report to the local SPD office, if abuse could not immediately be ruled out, for 3 of 5 sampled residents (#s 3, 4 and 6) with incidents or injuries of unknown cause. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia. Interviews with staff and review of the resident's clinical record were completed, including most recent service plan dated 03/15/24, temporary service plans (TSPs), incident reports and progress notes. The following was identified: * An incident report was completed on 02/15/24 at 11:30 am indicating Resident 4 was found with a skin tear to the left forearm. Staff stated "we are not sure how she acquired this skin tear". When asked, the resident could not explain how the injury occurred. There was no documented evidence the facility immediately reported the injury of unknown cause to the local SPD office. At the request of the survey team, the facility reported the incident to the local SPD and a confirmation was provided to the survey team prior to exit. The need to ensure all injuries of unknown cause were reported to the local SPD office, unless an immediate facility investigation reasonably concluded the injury was not the result of abuse, was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/03/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to promptly investigate incidents or injuries of unknown cause to rule-out abuse, document all required areas of an investigation, and report to the local SPD office, if abuse could not immediately be ruled out, for 3 of 5 sampled residents (#s 3, 4 and 6) with incidents or injuries of unknown cause. Findings include, but are not limited to:”

“Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to: During the survey, 04/01/24 through 04/04/24, observations of the facility showed bingo was conducted daily, a bus ride was offered on Tuesday, and ball bounce was played on Wednesday afternoon. No additional activities were observed during survey. Multiple residents were observed throughout the day wandering the halls, asleep in the living room, or watching TV in the living room. Review of the activity calendar showed three to five scheduled activities a day. All scheduled activities noted on the calendar were not observed during survey. Daily activities included snack and hydration pass and men's facial care. The men's facial care was observed to include shaving of male residents while in the living room. In an interview on 04/01/24, Staff 1 (Administrator) indicated the position of the activity aide was recently vacated and they were working to fill the opening. The need to ensure a daily activity program was provided for residents was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 04/03/24. They acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to: During the survey, 04/01/24 through 04/04/24, observations of the facility showed bingo was conducted daily, a bus ride was offered on Tuesday, and ball bounce was played on Wednesday afternoon. No additional activities were observed during survey. Multiple residents were observed throughout the day wandering the halls, asleep in the living room, or watching TV in the living room. Review of the activity calendar showed three to five scheduled activities a day. All scheduled activities noted on the calendar were not observed during survey. Daily activities included snack and hydration pass and men's facial care. The men's facial care was observed to include shaving of male residents while in the living room. In an interview on 04/01/24, Staff 1 (Administrator) indicated the position of the activity aide was recently vacated and they were working to fill the opening. The need to ensure a daily activity program was provided for residents was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 04/03/24. They acknowledged the findings. Activity calendar has been updated with social and recreational activities based on resident's individual and group interests.   Additionally, lobby bookcase has been utilized for holding textile activity books, games and fidget toys/books for carestaff to use when a resident does not want to participate in the group actvities.  These areas will be available for residents to enjoy at their leisure or with care staff assistance.   The Administrator will review the calendar monthly with the Activity Director prior to it being published.  Administrator will also monitor daily the activity calendar versus actual activity performed and the activity schedule for the day will be discussed at standup.  Administrator is responsible to see these corrections are completed and monitored. Activity calendar has been updated with social and recreational activities based on resident's individual and group interests.   Additionally, lobby bookcase has been utilized for holding textile activity books, games and fidget toys/books for carestaff to use when a resident does not want to participate in the group actvities.  These areas will be available for residents to enjoy at their leisure or with care staff assistance.   The Administrator will review the calendar monthly with the Activity Director prior to it being published.  Administrator will also monitor daily the activity calendar versus actual activity performed and the activity schedule for the day will be discussed at standup.  Administrator is responsible to see these corrections are completed and monitored. There are no detail notes for this visit.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs, provided clear direction for staff, and were consistently implemented by staff for 3 of 6 sampled residents (#s 1, 4, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 01/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 03/14/24, and progress notes, dated 01/22/24 to 03/26/24, were completed. Staff indicated the resident was dependent on staff for ADL care and required two staff for transfers. The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not followed by staff in the following areas: * Falls and safety interventions; * Behaviors during care; * Gait belt use and 1 person vs. 2 person transfers; * Toileting; * Activities; * Grooming; and * Mental health diagnoses. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/03/24. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 11/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 01/20/24, and progress notes, dated 01/07/24 to 04/01/24, were completed. Staff indicated the resident was able to complete several of his/her ADLs on his/her own. The resident required stand-by assist with bathing and occasionally toileting. The resident was able to ambulate and transfer on his/her own. The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not implemented by staff in the following areas: * Falls and safety interventions; * Resident-to-resident altercations; * Relationship with room 9; * PRN assistance with ADLs; * Activities; * Shower assistance; and * Agitation, exit seeking for a "gig," and behaviors related to room 9. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/03/24. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs, provided clear direction for staff, and were consistently implemented by staff for 3 of 6 sampled residents (#s 1, 4, and 6) whose service plans were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure there was documented monitoring at least weekly to resolution for short-term changes of condition, interventions were evaluated for effectiveness, and resident-specific interventions were determined, communicated to staff on all shifts, and implemented for 4 of 6 sampled residents (#s 1, 4, 5, and 6) reviewed with changes of condition. 1. Resident 5 was admitted to the facility in 01/2024 with diagnoses including dementia. The resident's service plan, dated 02/16/24, progress notes, dated 01/02/24 through 04/01/24, temporary service plans, and incident reports were reviewed. Staff were interviewed. The following was identified: The resident experienced multiple changes of condition: * 01/04/24 and 01/05/24 - multiple medications refused; * 01/11/24 - new diet; * 01/17/24 - report of a person entering his/her room when s/he was sleeping, laying next to him/her on the bed, and having "fought" the person; * 01/21/24 - medication refusals; * 02/16/24 - placed on alert charting upon returning to the facility the morning following an overnight visit with family; * 02/26/24 - medication change; and * 03/04/24 - medication changes. There was no documented evidence these short-term changes of condition were monitored through resolution. In addition, the resident experienced a severe weight gain, which was identified on 02/15/24. The significant change of condition was assessed by the facility RN, who determined the resident would be weighed weekly to monitor the weight gain. There was no documented evidence weekly weights were implemented for the resident. The need to implement determined interventions and monitor changes of condition through resolution, with progress noted at least weekly, was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure there was documented monitoring at least weekly to resolution for short-term changes of condition, interventions were evaluated for effectiveness, and resident-specific interventions were determined, communicated to staff on all shifts, and implemented for 4 of 6 sampled residents (#s 1, 4, 5, and 6) reviewed with changes of condition.”

“Based on interview and record review, it was determined the facility failed to ensure they staffed based on their Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to: Review of the ABST, the March and April 2024 staffing schedule, and the posted staffing plan was completed on 04/01/24 and 04/02/24. The facility was not staffing to or exceeding the indicated number of staff calculated by the tool for the day and evening shifts. The need to ensure the facility was staffed according to the ABST generated staff hours was discussed with Staff 1 (Administrator) on 04/02/24. She acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure they staffed based on their Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to: Review of the ABST, the March and April 2024 staffing schedule, and the posted staffing plan was completed on 04/01/24 and 04/02/24. The facility was not staffing to or exceeding the indicated number of staff calculated by the tool for the day and evening shifts. The need to ensure the facility was staffed according to the ABST generated staff hours was discussed with Staff 1 (Administrator) on 04/02/24. She acknowledged the findings. ABST was updated to accuratley reflect residents needs.  RN and RCC will update all residents monthly and at the time of a significant change.  After each update RCC will calculate care staff needs for each shift, day and staff based on those numbers. This will be evaluated monthly for 3 months and brought to next two Q.A.P.I. meetings.  Administrator is responsible to see that the corrections are completed and monitored. ABST was updated to accuratley reflect residents needs.  RN and RCC will update all residents monthly and at the time of a significant change.  After each update RCC will calculate care staff needs for each shift, day and staff based on those numbers. This will be evaluated monthly for 3 months and brought to next two Q.A.P.I. meetings.  Administrator is responsible to see that the corrections are completed and monitored. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted on alternating months, for all shifts, and that all required components were documented on the fire drill form in accordance with the Oregon Fire Code. Findings include, but are not limited to: Fire and life safety records, reviewed between 10/2023 and 03/2024, showed documentation was lacking in the following areas: * The escape route used; * Problems encountered; * Evidence of alternate routes used; * Evacuation time-period needed; and * The number of occupants evacuated. The fire drills were not completed at least every other month on alternating shifts. The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months, for all shifts, was discussed with Staff 1 (Administrator) and Staff 17 (Maintenance Director) on 04/02/24. The staff acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted on alternating months, for all shifts, and that all required components were documented on the fire drill form in accordance with the Oregon Fire Code. Findings include, but are not limited to: Fire and life safety records, reviewed between 10/2023 and 03/2024, showed documentation was lacking in the following areas: * The escape route used; * Problems encountered; * Evidence of alternate routes used; * Evacuation time-period needed; and * The number of occupants evacuated. The fire drills were not completed at least every other month on alternating shifts. The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months, for all shifts, was discussed with Staff 1 (Administrator) and Staff 17 (Maintenance Director) on 04/02/24. The staff acknowledged the findings. TELs documentation has been updated to include the following; escape route used, problems encountered, evidence of alternate routes used, evacuation time period needed and the number of occupants evacuated.  All Fire and Life Satey Fire Drills will be evaluated for 6 months, then brought to quarterly Q.A.P.I. meetings. Maintenance Director is responsible to see that this process is completed. Administrator to review documentation monthly. TELs documentation has been updated to include the following; escape route used, problems encountered, evidence of alternate routes used, evacuation time period needed and the number of occupants evacuated.  All Fire and Life Satey Fire Drills will be evaluated for 6 months, then brought to quarterly Q.A.P.I. meetings. Maintenance Director is responsible to see that this process is completed. Administrator to review documentation monthly. Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months of fire drills or conduct fire drills according to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to: Fire and life safety records, reviewed between 06/03/24 and 08/26/24, revealed the following: * Fire and life safety instruction was not consistently provided to staff on alternating months; and * There had been no fire drills completed between 06/03/24 and 08/26/24. In an interview on 08/26/20, Staff 17 (Maintenance Director) and Staff 1 (Administrator) acknowledged the facility failed to consistently provide life safety instruction to staff on alternating months and fire drills were not conducted according to the OFC. On 08/27/24 at 3:59 pm Staff 17 conducted a fire drill which included documentation of all required components. Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months of fire drills or conduct fire drills according to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to: Fire and life safety records, reviewed between 06/03/24 and 08/26/24, revealed the following: * Fire and life safety instruction was not consistently provided to staff on alternating months; and * There had been no fire drills completed between 06/03/24 and 08/26/24. In an interview on 08/26/20, Staff 17 (Maintenance Director) and Staff 1 (Administrator) acknowledged the facility failed to consistently provide life safety instruction to staff on alternating months and fire drills were not conducted according to the OFC. On 08/27/24 at 3:59 pm Staff 17 conducted a fire drill which included documentation of all required components. Fire drills will be happening monthly for nine months and fire and life safety instructions every other month. All fire and life safety drills will be evaluated monthly for nine months and brought to quarterly Q.A.P.I. meetings.   Maintenance Director is responsible to see that this is completed.  Administrator to review documentation monthly. Fire drills will be happening monthly for nine months and fire and life safety instructions every other month. All fire and life safety drills will be evaluated monthly for nine months and brought to quarterly Q.A.P.I. meetings.   Maintenance Director is responsible to see that this is completed.  Administrator to review documentation monthly. 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 in fire and life safety procedures at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (Administrator) on 04/02/24. There was no documentation of annual training conducted with residents related to general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. In an interview on 04/02/24, Staff 1 indicated the facility had not been conducting annual training with residents. She acknowledged there were residents currently in the facility who would be able to participate with fire and life safety training. Staff 1 further indicated they would implement a plan to address annual training with the residents who were able to understand. Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (Administrator) on 04/02/24. There was no documentation of annual training conducted with residents related to general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. In an interview on 04/02/24, Staff 1 indicated the facility had not been conducting annual training with residents. She acknowledged there were residents currently in the facility who would be able to participate with fire and life safety training. Staff 1 further indicated they would implement a plan to address annual training with the residents who were able to understand. TELs has been updated to include annual training in June conducted with residents related to general fire and life safety procedures, evacuation methods, responsiblities, and designated meeting places inside or outside the building in the event of a fire.  This will be evaluated annually at Q.A.P.I. and Safety Meeting following training .  Maintenace Director is responsible to see that the corrections are completed and monitored. Administrator to ensure annuall training has occurred. TELs has been updated to include annual training in June conducted with residents related to general fire and life safety procedures, evacuation methods, responsiblities, and designated meeting places inside or outside the building in the event of a fire.  This will be evaluated annually at Q.A.P.I. and Safety Meeting following training .  Maintenace Director is responsible to see that the corrections are completed and monitored. Administrator to ensure annuall training has occurred. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 420. Based on interview and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 420. Refer to C 420 Refer to C 420 There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 04/01/24 showed the following areas in need of cleaning or repair: * Multiple walls, doors, and door frames in the living room, dining room, and activity room had scrapes, dings, chips, missing pieces of plaster, spills, and/or black streaks; * A cupboard in the Jacuzzi room was damaged and the side was pulled apart, and a wall was scraped and chipped; * Walls in the laundry room had scrapes, splatters, and dings. The flooring in the east laundry room had a large section of missing linoleum around the drain. The west laundry room had small pieces of linoleum that were chipped and/or missing; * Numerous black scratches, deep gouges, and dings were noted on the flooring in the living room near the fireplace area; * Multiple areas of the laminate floor throughout the two front halls were pulling apart at the seams, creating a gap in the flooring. Several entry ways to bedrooms had no transition between the hall and bedroom flooring, which created a large gap between the two flooring types; * Numerous chairs located in the dining room, activity room, and hallway had missing vinyl, which left an exposed fabric layer. A sofa in the entryway of the building had a large tear in the left arm rest, with exposed stuffing. A recliner chair near the dining room had food spills and debris and dining room chairs had spills and debris on the seats and lower arms; * Window sills in the dining room had splatters, debris, and dead insects; * Strong, pervasive urine odors were present in Room 7 and the nearby hallway and alcove; these odors did not dissipate during the survey; * Courtyard doors and the facility's front door had significant scrapes and dings to the lower portions of the door; and * Two unused nurse's stations had scrapes, splatters, chips, and dings on the outer walls, inner walls, and/or corners were chipped with pieces of missing plaster. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 04/02/24. She acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 04/01/24 showed the following areas in need of cleaning or repair: * Multiple walls, doors, and door frames in the living room, dining room, and activity room had scrapes, dings, chips, missing pieces of plaster, spills, and/or black streaks; * A cupboard in the Jacuzzi room was damaged and the side was pulled apart, and a wall was scraped and chipped; * Walls in the laundry room had scrapes, splatters, and dings. The flooring in the east laundry room had a large section of missing linoleum around the drain. The west laundry room had small pieces of linoleum that were chipped and/or missing; * Numerous black scratches, deep gouges, and dings were noted on the flooring in the living room near the fireplace area; * Multiple areas of the laminate floor throughout the two front halls were pulling apart at the seams, creating a gap in the flooring. Several entry ways to bedrooms had no transition between the hall and bedroom flooring, which created a large gap between the two flooring types; * Numerous chairs located in the dining room, activity room, and hallway had missing vinyl, which left an exposed fabric layer. A sofa in the entryway of the building had a large tear in the left arm rest, with exposed stuffing. A recliner chair near the dining room had food spills and debris and dining room chairs had spills and debris on the seats and lower arms; * Window sills in the dining room had splatters, debris, and dead insects; * Strong, pervasive urine odors were present in Room 7 and the nearby hallway and alcove; these odors did not dissipate during the survey; * Courtyard doors and the facility's front door had significant scrapes and dings to the lower portions of the door; and * Two unused nurse's stations had scrapes, splatters, chips, and dings on the outer walls, inner walls, and/or corners were chipped with pieces of missing plaster. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 04/02/24. She acknowledged the findings. Walls, doors, and door frames in the living room, dining room and activity room fixed and/or cleaned.  Jacuzzi room cupboard fixed and wall repaired.  Both laundry room walls repaired and /or cleaned.   The flooring in both laundry rooms will be replaced after hoppers are moved to dirty side of laundry and dryers to clean side. Quotes and plan for work to be completed will be done by the date of compliance.  Laminate floors throughout two front halls where pulling apart at the seams, creating a gap are to be replaced along with the black deep scratches and dings noted in the lobby by the fireplace area.  Entry ways to bedrooms have been fixed with transition pieces.  New dining room chairs have been ordered and will arrive May 23rd.   Other chiars with damage have been cleaned, repaired or replaced.  Window sills in dining room have been cleaned.  Room 7 has been shampooed and is now on a shampooing schedule to twice a week to help odor control.  Doors to the courtyards and front doors have been repaired and  fixed with metal kick boards to help prevent scrapes and dings. Nurse's stations on East and West sides have been repaired and cleaned.   Maintenance Director will will do rounds daily of facility to identify issues that need attention and repair/clean as nessasary.   Administrator and Maintenace Director will do Facility rounds weekly for 6 weeks, then monthly for 3 months and then quarterly continuously. Maintenance Director is  reponsible to see these corrections are monitored. Walls, doors, and door frames in the living room, dining room and activity room fixed and/or cleaned.  Jacuzzi room cupboard fixed and wall repaired.  Both laundry room walls repaired and /or cleaned.   The flooring in both laundry rooms will be replaced after hoppers are moved to dirty side of laundry and dryers to clean side. Quotes and plan for work to be completed will be done by the date of compliance.  Laminate floors throughout two front halls where pulling apart at the seams, creating a gap are to be replaced along with the black deep scratches and dings noted in the lobby by the fireplace area.  Entry ways to bedrooms have been fixed with transition pieces.  New dining room chairs have been ordered and will arrive May 23rd.   Other chiars with damage have been cleaned, repaired or replaced.  Window sills in dining room have been cleaned.  Room 7 has been shampooed and is now on a shampooing schedule to twice a week to help odor control.  Doors to the courtyards and front doors have been repaired and  fixed with metal kick boards to help prevent scrapes and dings. Nurse's stations on East and West sides have been repaired and cleaned.   Maintenance Director will will do rounds daily of facility to identify issues that need attention and repair/clean as nessasary.   Administrator and Maintenace Director will do Facility rounds weekly for 6 weeks, then monthly for 3 months and then quarterly continuously. Maintenance Director is  reponsible to see these corrections are monitored. There are no detail notes for this visit.”

“Technical assistance was provided in the following area: (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. Technical assistance was provided in the following area: (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.”

“Technical assistance was provided in the following area related to H1518: (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. Technical assistance was provided in the following area related to H1518: (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 C231, C242, C361, C420, C422, and 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. Findings include, but are not limited to: Refer to C231, C242, C361, C420, C422, and C513. Refer to C231, C242, C361, C420, C422, and C513. Refer to C231, C242, C361, C420, C422, and 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. Findings include, but are not limited to: Refer to C 420. 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 420. Refer to C 420 Refer to C 420 There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 3, 13, and 20) completed all required pre-service orientation and dementia training topics; 3 of 3 staff (#s 13, 16, and 20) demonstrated competency in all assigned job duties within 30 days of hire; 2 of 2 long term staff (#s 4 and 14) completed the required number of annual in-service training hours, including annual infectious disease training and at least six hours of training on dementia care; and 2 of 2 long term non-care staff completed annual infectious disease training. Findings include, but are not limited to: Staff training records were reviewed on 04/03/24. The following was identified: 1. There was no documented evidence Staff 3 (RCC), hired 02/22/24, Staff 13 (CG), hired 01/31/24, and Staff (20), hired 01/11/24, completed one or more of the following pre-service orientation and dementia training topics: * Infectious Disease Prevention; * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and use of a person-centered approach; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and * Use of supportive devices with restraining qualities in memory care communities. 2. There was no documented evidence Staff 13 (CG), hired 01/31/24, Staff 16 (MT), hired 08/08/23, and Staff 20 (CG), hired 01/11/24, demonstrated competency in one or more of the following areas within 30 days of hire: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. 3. There was no documented evidence Staff 4 (CG), hired 07/31/20, and Staff 14 (MT), hired 04/07/21, 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. 4. There was no documented evidence Staff 5 (Dietary Aide), hired 09/21/18, and Staff 19 (Dietary Manager), hired 11/16/15, completed the required annual infectious disease training. 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 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 3, 13, and 20) completed all required pre-service orientation and dementia training topics; 3 of 3 staff (#s 13, 16, and 20) demonstrated competency in all assigned job duties within 30 days of hire; 2 of 2 long term staff (#s 4 and 14) completed the required number of annual in-service training hours, including annual infectious disease training and at least six hours of training on dementia care; and 2 of 2 long term non-care staff completed annual infectious disease training. Findings include, but are not limited to: Staff training records were reviewed on 04/03/24. The following was identified:”

“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 C260 and C270. 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 C260 and C270. Refer to C260 and C270. Refer to C260 and C270. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 2 of 6 sampled residents (#s 3 and 5) whose records were reviewed. Findings include, but are not limited to: Resident 3 and 5's current service plans, dated 03/19/24 and 02/16/24, respectively, were reviewed. Both service plans were found to be lacking information and staff instructions related to an individualized nutritional plan. The need to develop an individualized nutritional plan for each resident and include it in the service plan was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 2 of 6 sampled residents (#s 3 and 5) whose records were reviewed. Findings include, but are not limited to: Resident 3 and 5's current service plans, dated 03/19/24 and 02/16/24, respectively, were reviewed. Both service plans were found to be lacking information and staff instructions related to an individualized nutritional plan. The need to develop an individualized nutritional plan for each resident and include it in the service plan was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings. Service plans for #3 and #5 were updated with more information for an individualized nutrition and hydration plan.   All residents service plans have been updated to have more information for an individualized nutrition and hydration prferences and needs.   RN is responsible to audit 20% of Care Plans monthly ensuring nutrition and hydration plans are personalized for 5 months.  Results of audits will be discussed in Q.A.P.I. for the next 3 meetings. Service plans for #3 and #5 were updated with more information for an individualized nutrition and hydration plan.   All residents service plans have been updated to have more information for an individualized nutrition and hydration prferences and needs.   RN is responsible to audit 20% of Care Plans monthly ensuring nutrition and hydration plans are personalized for 5 months.  Results of audits will be discussed in Q.A.P.I. for the next 3 meetings. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to develop individualized activity plans from the evaluations completed, and ensure a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate based on residents' evaluations for 5 of 6 sampled residents' (#s 1, 3, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: A review of service plans for Residents 1, 3, 4, 5, and 6, and interviews with Staff 1 (Administrator) and Staff 21 (Activity Director) and during survey, revealed the following: 1. There was no documented evidence an individualized activity plan had been developed for Residents 1, 3, 4, 5, and 6 based on their activity evaluation that was reflective of the resident's activity preferences and needs. 2. There was no documented evidence a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate and based on the resident's evaluation. The need to ensure the facility developed an individualized activity plan based on the evaluation for each resident, and provided daily structured and non-structured activities based on the evaluation, was discussed with Staff 1, Staff 2 (RN), and Staff 3 (RCC) on 04/04/24. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to develop individualized activity plans from the evaluations completed, and ensure a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate based on residents' evaluations for 5 of 6 sampled residents' (#s 1, 3, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: A review of service plans for Residents 1, 3, 4, 5, and 6, and interviews with Staff 1 (Administrator) and Staff 21 (Activity Director) and during survey, revealed the following:”

“The findings of the kitchen inspection, conducted 12/18/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Sanitation Rules OARs 333-150-0000. The findings of the kitchen inspection, conducted 12/18/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Sanitation Rules OARs 333-150-0000.”