The findings of change of ownership survey, conducted 06/03/24 through 06/06/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 06/06/24, conducted 11/12/24-11/14/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 06/06/24, conducted 04/23/25 through 05/07/25 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 06/06/24, conducted 09/08/25 through 09/10/25 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the fourth re-visit to the re-licensure survey of 06/06/24, conducted 11/17/25 through 11/18/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure required postings were posted in a routinely accessible and conspicuous location to residents and visitors.  Findings include, but are not limited to:

The facility was divided into three memory care units: Pine, Oak, and Maple. On 09/09/25, observations of the facility's main lobby and separate MCC cottages revealed an absence of the following required postings:

* The name of the administrator or designee in charge;

* The current facility staffing plan;

* Resident Rights and Protections, including the LGBTQIA2S+ Rights and Protections; and

* LGBTQIA2S+ Nondiscrimination Notice.

In an interview with Staff 29 (Administrator) and Staff 2 (Chief Operating Officer) on 09/09/25 at 4:04 pm, they reported being unaware of the specific LGBTQIA2S+ postings required, or that all required postings needed to be accessible to residents in each separate cottage.

The need to ensure required postings are posted in a routinely accessible and conspicuous location for residents and visitors was reviewed with Staff 2, Staff 3 (RN), Staff 10 (Admissions Coordinator), and Staff 29 on 09/10/25 at 1:00 pm. They acknowledged the findings.

1.All mandated postings have been duly installed in the primary lobby area of the facility as well as within each individual cottage. LGBTQ policy and protections the Residents Rights and Protections, Manager on duty, and the daily staffing schedule.

2.A comprehensive list of required postings will be furnished to front desk personnel. Front desk coverage is maintained seven days per week.

3.The designated front desk staff member shall perform a weekly walkthrough inspection to verify that all postings remain properly displayed and clearly visible.

4.The Facility Administrator     

Based on interview and record review, it was determined the facility failed to ensure residents' rights to have a safe and homelike environment for multiple unsampled residents related to 1 of 1 sampled residents (#14) reviewed. Findings include, but are not limited to:

Resident 14 moved into the memory care community in 02/2025 with diagnosis including dementia with anxiety, Alzheimer's disease, and bowel and urinary incontinence.

The resident's record, including the most recent service plan, dated 02/05/25 with handwritten updates on 03/11/25, progress notes, dated 02/05/25 through 04/24/25, and temporary service plans were reviewed. Interviews with staff were conducted and the following was identified:

* 02/09/25: Resident 14 was "getting anxious and pacing around [Resident 14] was affecting [his/her] roommate with this behavior";

* 02/10/25: The resident "will take [a bowel movement] out of toilet and play with it";

* 02/10/25: Public urination in common areas;

* 02/12/25: The resident took a "hand full of feces [and] spread [it] all over the living room and dining room";

* 02/13/25: Resident 14 was "trying to get in [his/her] roommates bed";

* 02/24/25: The resident "plays with [his/her] feces and will wipe [it] on the wall";

* 02/24/25: The resident "will take off [his/her] clothes in common area and go to the bathroom on the floor";

* 03/24/25: "a few days ago" the resident "smeared feces all over another [resident's room]"; and

* 04/11/25: The resident was found out of bed and "messing with [his/her] roommate".

The resident's above noted exhibiting ongoing behaviors impacted the ability of multiple unsampled residents to live in a homelike environment.

The need to ensure residents rights and the right to live in a safe and homelike environment was reviewed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 6:36 pm. They acknowledged the findings.  

1: For Resident 14 the corrective actions taken was to update the service plan and provide increased education on interventions. Staff report effectiveness of interventions that redirect the noted behaviors. Increased the rounding on Resident 14 and increased the time needed on the ABST.

2: System updated with new requirements during Clinical review. 24-hour book reviewed the clinical team to discuss each behavior and possible interventions. Education provided on requirements of interventions for behaviors that affect not only the residents but also the other residents that live within the facility.

3: Clinical Team during clinical review to note if new behaviors have been identified and if current interventions are effective in mitigating the negative results of behaviors. Also review each QI of the month for the next three months than move to quarterly.

4: Clinical team during clinical review to complete the checks. Clinical reviews have LPN, RN, Administrator, RCC, and RCM. or a subset of listed members depending on the needs of the facility.

2. During the third revisit survey conducted from 09/08/25 through 09/10/25, multiple staff interviews identified that the facility failed to consistently maintain an adequate supply of incontinent briefs necessary to meet residents' needs and to ensure their rights to dignity and respect.

Interviews with staff between 09/08/25 and 09/10/25 revealed that due to the facility's failure to provide adequate incontinent briefs, staff were required to use briefs belonging to other residents when supplies were depleted.

As a result, residents were frequently placed in the wrong size incontinent briefs, compromising dignity, comfort, and placing them at risk for impaired skin integrity.

The need to ensure the facility maintained an adequate supply of incontinent supplies was discussed with Staff 2 (Chief Operating Officer), Staff 3 (Director of Nursing), Staff 10 (Admissions Coordinator), and Staff 29 (Administrator) on 09/10/25.

Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that protected privacy and dignity and provided a safe and homelike environment for multiple unsampled residents. This is a repeat citation. Findings include, but are not limited to:

1. The MCC cottages were designed such that the kitchens were open to resident dining rooms via a pass-through counter from which meals were served and caregivers had an unobstructed line of sight to the dining room. The dining room opened to a common area where residents and visitors could lounge and watch television.  

a. On 09/08/25 at 4:55 pm, Staff 24 (CG) stood at the kitchen counter and loudly asked Staff 36 (CG), who was escorting a resident from the common area to the dining room, whether two unsampled residents had had a bowel movement that day, using first names to identify those residents. Approximately 14 residents were seated in the dining room awaiting dinner service, and may have overheard the remarks.

b. On 09/08/25 at 4:17 pm, Staff 24 was observed providing ADL care for an unsampled resident with the bathroom door and the door to the room open to the common hallway; anyone passing by could potentially view the resident toileting.

The need to ensure the facility ensured residents received services in a manner that protected privacy and dignity and provided a safe and homelike environment was reviewed with Staff 2 (Chief Operations Officer), Staff 3 (Director of Nursing), Staff 10 (Admissions Coordinator), and Staff 29 (Administrator) on 09/10/25 at 1:00 pm.  They acknowledged the findings.

1.      Staff education provided to all staff members on the rights of the residents. Focusing on privacy and HIPAA compliance. Proper communication of residents activities including bowel and bladder logs to document without sharing to the cottage.

2.A. As part of the onboarding process, all newly hired employees will be required to review and formally acknowledge the residents' rights policy. Orientation will include a guided tour of the cottages, during which staff will be shown the designated locations for personal care supplies.

         B. All the cotteges have been given a Supplies sheet for eacch resident, to be turned into management as needed for personal supplies.

3.The facility shall conduct annual training for all staff members to reinforce the importance of safeguarding residents' rights and to ensure continued compliance with applicable standards.

4.This corrective action plan is being overseen and implemented under the direction of the Facility Administrator.     

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-to-resident physical altercations were immediately reported to the local SPD office, and /or injuries of unknown cause were reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse for 3 of 3 sampled residents (#s 4, 5 and 6) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the memory care facility in 04/2023 with diagnoses including dementia with behavioral disturbances.

The resident's service plan dated 05/29/24, incident investigation reports, progress notes from 03/01/24 through 06/03/24, observations of the resident, and interviews with care staff during the survey indicated the resident ambulated independently throughout the facility and had been involved in several resident-to-resident altercations.

The resident's clinical record revealed the following:

* 03/15/24: "Another resident notified caregivers that resident's [Resident 4] hand was bleeding ... Resident has 2 skin tears on hand ... Resident is unable to explain how skin tear was caused ..."

Although the facility completed an incident investigation report, there was no evidence the injury of unknown cause had been reported to the local SPD office as required.

In an interview with Staff 8 (LPN) on 06/05/24 at 4:25 pm, she reviewed the resident's record and stated the incident had not been reported to the local SPD. She was asked to report the incident.

Findings were reviewed with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. The findings were acknowledged. Case intake numbers were provided prior to survey exit.

2. Resident 5 moved into the memory care community in 03/2020 with diagnoses including vascular dementia.

Review of the resident's 03/01/24 through 06/03/24 progress notes showed the following:

* 03/21/24 "Resident has a light yellow discoloration on left knee.";

* 03/28/24 "Resident had discoloration on [his/her] left forearm and hand.";

* 05/02/24 "Resident has 2 small discoloration spots on right knee"; and

* 05/10/24 "discoloration on left arm."

In a 06/05/24 interview with Staff 1 (Administrator), she reported when staff identified skin issues, the skin issues would be reported to the facility nurse who would follow up on the skin injuries. She confirmed there was no incident report or other document confirming the facility conducted an immediate investigation into the injuries to conclude the injuries were not the result of abuse or neglect to Resident 5.

On 06/05/24 at 12:38 pm, Staff 1 confirmed the physical injury had not been investigated nor reported to the local unit. The surveyor requested Staff 1 report the incident to the local SPD office. Confirmation that the report had been sent to the local APD office was provided prior to survey exit.

The need to ensure investigations into physical injuries of unknown cause were documented to include the injuries were not the result of abuse or neglect was discussed with Staff 1 on 06/05/24 and Staff 8 (LPN) on 06/06/24. They acknowledged the findings.

3. Resident 6 moved into the memory care community in 03/2024 with diagnoses including Alzheimer's disease.

Review of the resident's 03/21/24 through 06/01/24 progress notes showed the following:

* 04/16/24 - Bruising "right lower butcheek and right arm";

* 04/30/24 - " a baseball sized bruise with like a road rash or rug burn on the inside.";

* 05/12/24 - " Open area on right side of buttocks"; and

* 05/26/24 - "bruising/discoloration to arm and bottom"

In a 06/05/24 interview with Staff 1 (Administrator), she reported when staff identified skin issues, the skin issues would be reported to the facility nurse who would follow up on the skin injuries. She stated that she was going to check documentation of the the physical injury.

On 06/05/24 at 4:00 pm, Staff 1 confirmed there was no documented evidence the facility conducted an immediate investigation to reasonably conclude the above physical injuries were not the result of abuse and it was not reported to the local SPD office. The surveyor requested Staff 1 report the incident to the local SPD office. Confirmation that the report had been sent to local APD office was provided prior to survey exit.

The need to ensure investigations into physical injuries of unknown cause were documented to include the injuries were not the result of abuse or neglect was discussed with Staff 1 on 06/05/24 and Staff 8 (LPN) on 06/06/24. They acknowledged the findings.

1. C231:The injuries of unknown origin were reported to APs, and intake numbers were obtained.

2. C231: On 6/11/24, employees attended a staff in-service on abuse reporting and injury of unknown origin reporting.

3. C231: The resident care manager will monitor skin sheets and follow up on any areas of concern daily and weekly.

4. C231: The LPN will be responsible for following up and processing any changes of condition.

2. Resident 13 moved into the memory care community in 08/2024 with diagnoses including dementia.

Review of the resident's 01/22/25 through 04/23/25 progress notes showed the following:

* 02/15/25: Open area on the left leg.

In an interview with Staff 8 (LPN) on 04/24/25 at 1:50 pm, she reported there was no incident report or other documentation confirming the facility conducted an immediate investigation into the injuries to conclude the injury was not the result of abuse or potential abuse to Resident 13.

The surveyor requested Staff 8 report the incident to the local SPD office. Confirmation that the report had been sent to the local SPD office was provided prior to survey exit.

The need to ensure investigations into physical injuries of unknown cause were documented to include the injuries were not the result of abuse or potential abuse was discussed with Staff 8 and Staff 29 (ED) on 04/24/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to immediately investigate incidents of abuse, suspected abuse, or an injury of unknown cause to rule out possible abuse or report to the local SPD office if abuse could not be ruled out, and take measures necessary to protect residents and prevent the reoccurrence of abuse, for 3 of 3 sampled residents (#s 11, 13, and 14) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 11 moved into the memory care community in 04/2023 with diagnoses including dementia.   

The resident's facility records including progress notes, dated from 01/20/24 through 04/23/25, the 09/23/24 service plan that was available to staff, Temporary Service Plans, dated from 01/02/25 through 04/03/25, and Incident Reports were reviewed.

There was no documented evidence the following incidents were reported to the local SPD office or that the facility had immediately investigated the incidents in order to rule out abuse or suspected abuse, and/or take measures necessary to protect residents and prevent the reoccurrence of abuse:

* 12/20/24: Staff documented in a progress note, "Resident has dark purple bruising to left hand" with no other documentation of how or when Resident 11 sustained the bruising;

* 01/03/25: Staff documented in a progress note, "bruising to right hand is not longer visible" with no other documentation of how or when the resident sustained the bruising; and

* 01/17/25: Staff documented in a progress note, "resident has new discoloration to left hand, resident unable to state where it came from."    

A copy of the confirmations that the facility reported the above incidents to the local SPD office was provided on 04/24/25.

The need to ensure the facility immediately investigated incidents of abuse, suspected abuse, or an injury of unknown cause to rule out possible abuse or report to the local SPD office if abuse could not be ruled out was reviewed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 5:14 pm. They acknowledged the findings.   

3. Resident 14 moved into the memory care community in 02/2025 with diagnosis including dementia with anxiety, Alzheimer's disease, and vertigo.

The resident's record, including the most recent service plan, dated 02/05/25 with handwritten updates on 03/11/25, progress notes, dated 02/05/25 through 04/24/25, and Temporary Service Plans were reviewed. The following was identified:

There was no documented evidence the following incidents were reported to the local SPD office or that the facility had immediately investigated the issue in order to rule out abuse or possible abuse:

* 02/10/25: The resident "will pour water on other residents";

* 02/10/25: Resident 14 "was hitting staff and other residents";

* 02/14/25: "Discoloration on top of right foot";

* 02/14/25: Skin tear on back of hand;

* 03/07/25: Bruise to right arm "yellow in color"; and

* 03/17/25: "red marks on shoulder".

On 04/24/25 at 4:00 pm, survey requested facility staff report the above incidents to local SPD and confirmation of the reports was received at 6:27 pm.

The need to ensure the facility immediately investigated incidents of abuse, suspected abuse, or an injury of unknown cause to rule out possible abuse or report to the local SPD office if abuse could not be ruled out was reviewed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 6:36 pm. They acknowledged the findings.   

1: Corrective actions were completed prior to state survey leaving the facility. All APS reports sent with investigations attached. Confirmation of fax to APS received prior to exit of state survey.

2: The System has been updated with education provided on incident reporting by the shower aid. Shower sheets plus incident reporting of unknown injuries education completed.

3: Five days a week during clinical review.  

4: Clinical staff participating in clinical review. I.E.Administrator, RN, LPN, RCC, RCM. or subset of  

Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large. Findings include, but are not limited to:

The facility was divided into three memory care units: Pine, Oak, and Maple. At the time of the survey the facility was home to 52 residents: 16, 18, and 17, respectively.

During the interview on 06/05/24 at 1:40 pm, Staff 6 (Activities Director) stated she hosted or facilitated resident activities during her scheduled hours Monday through Friday. Weekend activities were scheduled to be facilitated by caregivers.

During the interview with Staff 17 (CG) and Staff 24 (CG) on 06/05/24 at 2:10 pm both confirmed facility staff conducted the activities during weekends but only in the afternoon and depending on staff's availability.

The June 2024 Activity Program calendar provided to the survey team indicated the following activities would occur during the survey:

06/03/24:

* Caregiver planned activities

06/04/24:

* 10:00 am - Seated stretch program

* 2:00 pm - Balloon Toss

06/05/24:

* 10:00 am - Breathing and Yoga program

* 2:00 pm - Painting seashells

06/06/24:

* 10:00 am - Seated Cardio program

a. Observations in the Oak and Pine Units, from 06/03/24 through 06/05/24, revealed most of the activities listed on the calendar were either not held or substituted with a different activity in each unit. A television played continuously in both units, and residents were observed in their rooms, wandering the halls, or sitting asleep in common areas for long periods of time.  

b. Random observations in the Maple Unit from 06/04/24 thorough 06/05/24 revealed the following facility led activities occurred:

- 06/04/24 at 11:10 am: Seated stretch program; and

- 06/05/24 at approximately 3:30 pm: Painting.

No other facility led activities occurred in the Maple unit.

The need to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large was reviewed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings. No further information was provided.

1. C242: The facility will designate a staff member to be responsible for activities daily until a full-time activity person can be hired and trained.

2. C242: The Resident Care Manager will monitor cottages daily to ensure the planned daily activities are completed. When the Resident Care Manager is off, the Resident Care Coordinator will conduct the walking rounds to ensure activities are being completed.

3. C242: Individual activity assessments will be completed for each resident by July 30th, 2024.

4. C242: The Resident Care Manager will ensure the activity assessments are completed.

Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large. This is a repeat citation. Findings include, but are not limited to:

The facility was divided into three memory care units: Pine, Oak, and Maple. At the time of the survey the facility was home to 53 residents: 19, 17 and 17, respectively.

At the time of the survey, the Activity Coordinator was off work. on personal leave. In an interview on 09/10/25, Staff 2 (Chief Operating Officer) acknowledged the Activity Coordinator had been off work and direct care staff were expected to be providing activities for the residents.

The activity calendar that was posted in each unit was for the month of August. Staff 17 (CG) confirmed no activity calendar had been developed for September and the Activity Coordinator had been off work for the past "two or three weeks."

The August calendar indicated one activity was scheduled in each unit in the morning and after lunch. The activities were scheduled to last between 30 minutes and one hour, except where a movie was scheduled. Staff explained that the Activity Assistant had led the activities until she went on leave.

Observations by the survey team while they were on survey in the building between approximately 2:30 pm - 5:00 pm on 09/08/25, 8:30 am - 5:00 pm on 09/09/25 and 8:30 am - 12:00 pm 09/10/25 noted the activities provided to residents were:

* 2 to 3 residents on the Maple and Oak units were offered coloring sheets;

* 2 residents on the Pine unit sat at the dining table and read through some picture books and magazines;

* A CG painted one resident's finger nails on the Pine unit on 09/08/25; and

* A CG on the Oak unit was trying to engage 3 - 4 residents in kicking a large ball between them on 09/09/25.

In each unit during the survey, there were some residents who were in their rooms, 5 -6 residents sitting in the living room area on couches while the TV played a movie or TV show, and several residents roaming the hallways. A few residents sat on the couches or at a dining table or in front of the fireplace and occasionally conversed with each other. Occasionally, when staff had time, a CG would sit on a couch and talk with some residents.

In an interview on 09/10/25, Staff 24 (CG) stated CGs found it difficult to provide activities for residents because they lacked supplies and guidance. Staff 24 said the only activity she felt CGs offered were coloring sheets and acknowledged residents often got bored of the same activity.

The facility lacked a daily program of social and recreational activities that addressed resident interests and met their physical, mental, and psychosocial needs.

The need to develop and implement an activity program was discussed with Staff 29 (Administrator), Staff 3 (Director of Nursing) and Staff 2 (Chief Operating Officer) on 09/09/25 and 09/10/25. They acknowledged the facility had not been providing activities.

1.The facility has appointed a full-time Activities Director to oversee the planning and implementation of resident engagement programs. Resident specific preferences are captured and put into the residents care plan

2.An Activities Assistant will be designated to ensure continuity of services in the event of unforeseen circumstances or staff absences, or designee. Thereby maintaining uninterrupted departmental operations.

3.The Activities Department will be subject to weekly evaluations conducted through scheduled walkthroughs to verify adherence to the posted activity calendar. Additionally, a monthly planning meeting will be held to review and finalize the calendar for the upcoming month.

4.These measures are being implemented under the supervision and authority of the Facility Administrator.

3. Resident 4 was admitted to the memory care facility in 04/2023 with diagnoses including dementia with behavioral disturbances.

During the acuity interview on 06/03/24 and an interview with Staff 8 (LPN) on 06/05/24 at 2:50 pm, staff stated quarterly and significant change evaluations and service plans were combined into one document.

Observations of the resident, staff interviews, and review of the record during the survey revealed s/he needed staff assistance with ADL care needs and did not advocate for him/herself or request assistance. Between 03/01/24 and 06/03/24, the resident had experienced falls, hospitalizations, several resident-to-resident altercations, medication changes, skin injuries, and home health services.

Resident 4's most recent evaluation, dated 05/29/24, was not reflective of the resident's health status or current needs, in the following areas:

* Customary routines: bathing;

* Visits to the health practitioner(s), ER, hospital in the past year;

* Personality: including how the person copes with change or challenging situations;

* Eating and dental status;

* Ability to use call system;

* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;

* Indicators of nursing needs;

* Fall risk or history;

* History of dehydration or unexplained weight loss or gain;

* Recent losses; and

* Environmental factors that impact the resident's behavior including but not limited to: noise, lighting, and room temperature.

The need to ensure Resident 4's evaluation was reflective of his/her health status and current needs was discussed with Staff 8 (LPN) on 06/05/24 at 2:50 pm, and with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings. No other information was shared.

4. Resident 3 was admitted to the memory care facility in 09/2023 with diagnoses including dementia, depression, and diabetes.

During an interview with Staff 8 (LPN) on 06/05/24 at 2:50 pm, she stated Resident 3's quarterly evaluation and service plan were combined into one document.

Observations and interview with the resident, staff interviews, and review of the record during the survey were conducted.

Resident 3's most recent evaluation, dated 04/08/24, was not reflective of the resident's health status or current needs in the following areas:

* Customary routines: sleeping, eating and bathing;

* Visits to the health practitioner(s), ER, hospital in the past year;

* Mental health issues including: presence of depression, thought disorders or behavioral or mood problems;

* Personality: including how the person copes with change or challenging situations;

* Ability to use call system;

* Pain: non-pharmaceutical interventions, including how a person expresses pain or discomfort;

* Nutritional habits and fluid preferences;

* History of dehydration or unexplained weight loss or gain;

* Recent losses; and

* Environmental factors that impact the resident's behavior including but not limited to: noise, lighting, and room temperature.

The need to ensure Resident 3's evaluation was reflective of his/her health status and current needs was discussed with Staff 8 (LPN) on 06/05/24 at 2:50 pm, and with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings. No other information was shared.

Based on observation, interview, and record review, it was determined the facility failed to ensure initial evaluations addressed all the required elements, for 1 of 1 newly admitted resident (# 6) and quarterly evaluations were the foundation used to develop residents' quarterly service plans, including documentation relevant to the residents' needs and current condition for 3 of 5 sampled residents (#s 3, 4 and 5) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 6 moved into the memory care community in 03/2024 with diagnoses including Alzheimer's disease.

The resident's initial evaluation was reviewed and it failed to address the following required elements:

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

* Physical health status including vital signs if indicated by diagnosis, health problems or medications;

* Personality including how the person copes with change or challenging situations;

* List of treatments;

* Smoking, ability to smoke safely;

* Alcohol and drug use; and

* Environmental factors that impact the resident's behaviors including, but not limited to noise, lighting, room temperature.

The need to ensure the initial evaluation included all required elements was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer) and Staff 8 (LPN) during interviews on 06/05/24 and 06/06/24. Staff acknowledged the findings.

2. Resident 5 moved into the memory care facility in 03/2020 with diagnoses including vascular dementia.

During an interview with Staff 2 (Chief Operating Officer) on 06/03/24, he reported the resident's quarterly evaluation and service plan were combined into one document.

Observations of the resident, staff interviews, and review of the record during the survey were conducted. Between 03/01/24 and 06/03/24, the resident had experienced falls, hospitalizations, and skin injuries.

Resident 5's most recent evaluation, dated 04/02/24, was not reflective of the resident's health status and current needs in the following areas:

* Customary routines: sleeping, eating and bathing;

* Personality: including how the person copes with change or challenging situations;

* Ability to use call system;

* Hydration and nutrition status; and

* Environmental factors that impact the resident's behavior including but not limited to: noise, lighting, and room temperature.

The need to ensure Resident 5's evaluation was reflective of his/her health status and current needs was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24 at 5:28 pm. They acknowledged the findings.

1. C252: The facility has ensured the proper evaluation form is currently in use.

2. C252: Service plans will be updated with all of the identified information by 8/5/24.

3. C252: Staff have attended an in-service training to address the completion of service plans.

4. C252: The Resident Care Manager will update service plans weekly as needed. The service plan team will meet to review updates to the service plans.

3. Resident 3 was admitted to the facility in 09/2023 with diagnoses including dementia and diabetes.

Observations and interview with the resident, interviews with staff, review of the resident's 04/08/24 evaluation and service plan, 03/01/24 through 06/03/24 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident's service plan, dated 04/28/24, was not reflective and/or lacked resident-specific direction for staff including who, what, when, how and how often to provide service in the following areas:

* Who to report new complaints of pain;

* Frequency of safety checks;

* Activities and life enrichment;

* Bathing;

* Housekeeping;

* Medication management;

* Laundry assistance;

* Making bed; and

* Personal shopping assistance.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff including who, what, when, how and how often to provide service was discussed with Staff 8 (LPN) on 06/05/24 at 2:50 pm, and with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings. No further information was provided.  

4. Resident 4 was admitted to the memory care facility in 04/2023 with diagnoses including dementia with behavioral disturbances.

Observations of the resident, interviews with staff, review of the resident's 05/29/24 evaluation and service plan, 03/01/24 through 06/03/24 temporary service plans, progress notes, physician communications, home health visit notes, and incident investigations were completed.

The resident's service plan was not reflective and/or lacked resident-specific direction for staff including who, what, when, how and how often to provide service in the following areas:

* Toileting assistance;

* Transportation;

* Activities and life enrichment;

* Bathing;

* Housekeeping: "Daily tidy by care staff";

* Medication management;

* Dressing/undressing;

* Diet;

* Use of glasses; and

* Grooming.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff including who, what, when, how and how often to provide service was discussed with Staff 8 (LPN) on 06/05/24 at 2:50 pm, and with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings. No further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs, and included a written description of who shall provide the services and when, how, and how often the services shall be provided, for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5 moved into the memory care community in 03/2020 with diagnoses including vascular dementia.

The resident's 04/02/24 service plan, 05/24/24 through 05/29/24 temporary service plans, were reviewed, observations were made, and interviews with caregivers were conducted between 06/03/24 and 06/05/24.

Resident 5's service plan was not reflective, and did not provide clear direction to staff including what, when and how often services shall be provided in the following areas:

* Use of fall mattress;

* Activities and life enrichment;

* A relationship with another resident;

* Assistance needed for toileting and dressing;

* Health shakes status;

* Oral health status; and

* Use of glasses.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff including what, when and how often services shall be provided was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. The findings were acknowledged.

2. Resident 6 moved into the memory care community in 03/2024 with diagnoses including Alzheimer's disease.

The resident's 05/09/24 service plan and 04/29/24 through 05/24/24 temporary service plans, were reviewed, observations were made, and interviews with caregivers were conducted between 06/03/24 and 06/05/24.

Resident 6's service plan was not reflective, and did not provide clear direction to staff including what, when and how often services shall be provided in the following areas:

* A relationship with another resident;

* Activities and life enrichment;

* Cognition, including memory, orientation, confusion and decision making abilities;

* Use of a walker for ambulation; and

* Use of a splint on ring finger.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff including what, when and how often services shall be provided was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. The findings were acknowledged.

5. Resident 1 was admitted to the memory care facility in 02/2023 with diagnoses including dementia without behavioral disturbances.

Observations of the resident, interviews with staff, review of the resident's 05/01/24 service plan, 05/17/24 temporary service plan, progress notes, and home health visit notes were completed.

The resident's service plan was not reflective and/or lacked resident-specific direction for staff including who, what, when, how and how often to provide service in the following areas:

* Activities and life enrichment;

* Eating including safe feeding instructions and protein shake status; and

* Hospice comfort care interventions.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff including who, what, when, how and how often services shall be provided was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. The findings were acknowledged.

6. Resident 2 was admitted to the memory care facility in 02/2023 with diagnoses including cerbrovascular accident (stroke) and dementia without behaviors.

Observations of the resident, interviews with staff, review of the resident's 05/01/24 service plan, 03/13/24 through 05/15/24 temporary service plans, progress notes, physician communications and home health visit notes were completed.

The resident's service plan was not reflective and/or lacked resident-specific direction for staff including who, what, when, how and how often to provide service in the following areas:

* Activities and life enrichment;

* Eating including signs/symptoms of aspiration and safe swallow instructions;

* Transfers including step by step instructions for two person transfer; and

* Hospice comfort care interventions.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff including who, what, when, how and how often services shall be provided was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. The findings were acknowledged.

1. C260: All resident service plans will be updated by the service plan team.

2. C260: The service plan team will receive training by the regional nurse and administrator to ensure all aspects of the service plan are person-centered for each resident.

3. C260: The facility administrator will meet with the service plan team weekly until completed.

4. C260: Facility Administrator.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and provided clear direction to staff regarding the delivery of services, for 2 of 3 sampled residents (#s 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the memory care community in 05/2024 with diagnoses including Alzheimer's disease and anxiety.

The resident's current service plan dated 09/25/24 was reviewed, observations were made, and interviews with caregivers were conducted between 11/12/24 and 11/14/24. Resident 8's service plan was not reflective and did not provide clear direction to staff in the following areas:

* Level of assistance for eating;

* Meal assistance needs, including pacing strategies;

* Preference of eating with hands;

* Level of assistance for bathing;

* Level of assistance for dressing/undressing;

* Level of assistance with brief changes;

* Behavior of taking other residents' food; and

* Use of chew toy.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer), Staff 3 (RN), and Staff 8 (LPN) on 11/14/24. They acknowledged the findings.

 2. Resident 7 moved into the memory care community in 09/2022 with diagnoses including Alzheimer's disease.

Observations of the resident, interviews with staff, and the 11/01/24 service plan and Temporary Service Plans (TSPs) from 08/16/24 through 10/30/24 were reviewed during the survey and identified Resident 7's service plan was not reflective of his/her status and did not provide clear direction regarding the delivery of services in the following areas:  

* Use of PPE (Personal Protective Equipment) for bowel incontinence care;

* Use of an air mattress;

* Two staff to assist with bathroom use and dressing;

* Cognition status including ability to choose clothing and menu items;

* Morning care assistance;

* Shower assistance; and

* Use of wheelchair with a pressure sensor.

On 11/14/24 at 11:09 am, the service plan was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer) and Staff 3 (Facility RN). Staff acknowledged the service plan was not reflective of the resident's status and lacked clear direction to staff.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans that were available to staff were updated quarterly, reflective of residents' current care needs and preferences, provided clear direction regarding the delivery of services, or were implemented for 4 of 4 sampled residents (#s 11, 12, 13 and 14) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 13 moved into the facility in 08/2024 with diagnoses including dementia without behavioral disturbance and anxiety.

Observations were made of the resident and interviews were conducted with facility staff. The service plan, dated 03/27/25, and Temporary Service Plans, dated 12/16/24 through 03/28/25, were reviewed during the survey and revealed Resident 13's service plan was not reflective of his/her status and did not provide clear direction regarding the delivery of services the following areas:

* Use of a floor mattress;

* Use of a wheelchair;

* The method of taking medication: crushed medication versus whole;

* Use of partial dentures and instructions for cleaning and storing them; and

* Transfer status.

The need to ensure service plans were reflective of resident needs and preferences and provided clear direction to staff was discussed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 1:50 pm. The findings were acknowledged.

3. Resident 11 moved into the memory care community in 04/2023 with diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety.

The service plan available to staff, dated 09/23/24, and Temporary Service Plans, dated 01/02/25 through 04/03/25, were reviewed. Observations were made of the resident and staff were interviewed. The service plan was not reflective of the resident's status, did not provide clear direction regarding the delivery of services, nor was implemented in the following areas:

* Behaviors and what triggers the behaviors;

* Behavior interventions;

* Caregiving staff to apply powder after assisting the resident to the restroom;

* Ability to verbalize pain;

* The use of a bed and chair alarm;

* Chronic skin condition;

* Transfers best when s/he has something to hold on to (e.g. grab bar);

* Preferred beverages;

* Staff are to assist with brushing his/her teeth after every meal; and

* Staff assistance needed for daily telephone calls to spouse.

On 04/24/25 at 1:13 pm, Staff 8 (LPN) reported that she had updated Resident 11's service plan since 09/23/24 and stated, "We've had a problem with staff not filing [the service plans] and leaving them around [on the unit]."

The need to ensure updated service plans were available to staff, were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 8 and Staff 29 (ED) on 04/24/25 at 5:14 pm. They acknowledged the findings.

4. Resident 12 moved into the memory care community in 12/2024 with diagnoses including unspecified dementia.

The service plan, dated 03/06/25, and Temporary Service Plans, dated 01/02/25 through 01/24/25, were reviewed. Observations were made of the resident and staff were interviewed. The service plan was not reflective of the resident's status and/or did not provide clear direction regarding the delivery of services in the following areas:

* Specific details relating to hallucinations or delusions (e.g. what they relate to and what staff need to do when the resident exhibits them);

* Resident's preference of staff to negate shower refusals;

* Fall interventions including room checks every one to two hours as the resident spills food and/or beverages in his/her unit;

* The utilization of the pull cord to request staff assistance;

* Caregivers to apply lotion to his/her head and face daily;

* Dressing assistance to help negate multiple layers of clothing; and

* Where the resident's unit key was located.

The need to ensure updated service plans were available to staff, were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 5:14 pm. They acknowledged the findings.

2. Resident 14 moved into the memory care community in 02/2025 with diagnosis including dementia with anxiety, Alzheimer's disease, vertigo, and bowel and urinary incontinence.

The resident's record, including the most recent service plan, dated 02/05/25 with handwritten updates dated on 03/11/25, progress notes, dated 02/05/25 through 04/24/25, and Temporary Service Plans were reviewed, observations were made, and interviews with staff were conducted. The following was identified:

The resident's service plan was not reflective of residents current needs and did not provide clear direction regarding the delivery of services in the following areas:

* Behaviors and interventions;

* Sleep routine including insomnia and daytime naps, and resident preferences;

* Evacuation status;

* Pain interventions and how to identify;

* Reluctant to accept care;

* Elopement status;

* Bathing status and assistance needed;

* Cognition status;

* Dressing and undressing status;

* How the resident communicates;

* Eating, meals, and hydration status and instruction to staff;

* Ability to eat independently;

* Vision and use of glasses;

* Personal hygiene status and assist level needed;

* Mobility status;

* Toileting status;

* Transferring status;

* Hospice services;

* Use of weighted blanket and weighted stuffed animals;

* Resident environmental preferences including temperature;

* Interest in housekeeping tasks and when a staff member danced with him/her; and

* Behaviors related to after the resident's spouse visited the facility.

The need to ensure the resident's service plan was reflective of resident's current needs and provided clear direction regarding the delivery of services was reviewed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 6:36 pm. They acknowledged the findings.  

1: Service plan binders have been purged and new updated service plans in the cottages.

Corrective Action for Resident 13 service plan updated to reflect the noted deficit areas. Use of floor mattress; the method of taking medications; crushed vs whole; Use of partial dentures and instructions for cleaning and storing them; and transfer status. service plan placed in cottage for staff to have available. Once the update was completed the new service plan was placed in the service plan binder in an appropriate cottage.

Corrective Action for Resident 14 service plan updated to reflect the noted deficit areas. Behaviors and interventions; sleep routine including insomnia and daytime naps, and resident preferences; evacuation status; pain interventions and how to identify; reluctant to accept care; elopement status; bathing status and assistance needed; cognition status; dressing and undressing status; how the resident communicates; eating, meals, and hydration status and instruction to staff; ability to eat independently; Vision and use of glasses; personal hygiene status and assist level needed; Mobility status; toileting status; transferring status; hospice services; use of weighted blanket and weighted stuffed animals; resident environmental preferences including temperature; interest in housekeeping tasks and when a staff member danced with her; and behaviors related to after the resident's spouse visited the facility. Once completed the new service plan was placed in the cottage in the service plan bind to be available for care staff to have access.

Corrective action for resident 11 service plan was updated to reflect the noted deficit areas: Behaviors and what triggers the behaviors; behavior interventions; caregiving staff to apply powder after assisting the resident to the restroom; Ability to verbalize pain; the use of a bed and chair alarm; Chronic skin condition; Transfers best when she has something to hold on to (e.g. grab bar): Preferred beverages; Staff are to assist with brushing his teeth after every meal; and staff assistance needed for daily telephone calls to spouse. Service plan was updated and a copy was placed in the Service plan binder in the appropriate cottage for care staff to have access.

Corrective action for resident 12 service plan was updated to reflect the noted deficit areas: Specific details relating to hallucinations or delusions (e.g. what they relate to and what staff need to do when the resident exhibits them); Resident's preference of staff to negate shower refusals; Fall interventions including room checks every one to two hours as the resident spills food and /or beverages in her unit; the utilization of the pull cord to request staff assistance; Caregivers to apply lotion to her head and face daily; dressing assistance to help negate multiple layers of clothing; and there the resident's unit key was located.

2: Correction to the system to prevent future occurrences has been implemented by Care plan service binder review once a week making sure the updated care plans are in the service binders and the old service plans are place in the hard chart.

Updates via TSP are to be reviewed each clinical review and placed in the service plan binder if the interventions are to be added to the service plan during the 90 day review period.

3. Service plan and TSP to be reviewed each clinical review and weekly checks to make sure all Service plan binders are up to date.

4. Clinical review team consistent of RN, LPN, Administrator, RCC, and RCM or a subset of the listed persons.

Based on interview and record review, it was determined the facility failed to ensure service plans provided clear direction to staff regarding the delivery of services, for 4 of 8 sampled residents (#s 5, 6, 17 and 20) whose service plans were reviewed. This is a repeat citation Findings include, but are not limited to:

Residents 5, 6, 17 and 20 were admitted to the facility with diagnoses including dementia.

Interviews with staff, and review of service plans showed the plans were not reflective of the residents' current behaviors and did not provide clear direction to staff in the following area:

* Affectionate physical behaviors towards other residents.

Interviews with multiple staff on 09/09/25 and 09/10/25 revealed that Residents 5 and 6 were frequently observed together, holding hands, hugging, or kissing. Staff also reported that Residents 6 and 17 were physically affectionate with each other, and that Residents 5, 6 and 17 were observed together on multiple occasions. In addition, staff reported Resident 20 was in a relationship with two other sampled residents.

Service plans for residents 5, 6, 17 and 20 did not address these affectionate physical behaviors or provide staff clear direction on interventions, monitoring, or appropriate staff response.

The need to ensure resident service plans were reflective of current behaviors and provided direction to staff was discussed with Staff 2 (Chief Operating Officer), Staff 3 (Director of Nursing), Staff 10 (Admissions Coordinator) and Staff 29 (Administrator) on 09/10/25.

1.A relationship log has been distributed to direct care staff and placed within the care plan binder for reference. Additionally, resident relationship information has been integrated into the Point of Care electronic medication administration record (eMAR) system.

2.Staff are required to document observations related to resident relationships during each shift to facilitate ongoing monitoring and identification of any changes.

3.The relationship log and associated documentation will be reviewed weekly during the clinical stand-up meeting to ensure consistency and accuracy in reporting.

4.Clinical staff shall maintain responsibility for oversight and discussion of resident relationship documentation during regularly scheduled clinical meetings.  

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 5 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

Resident 1, 2 and 3's current service plans were reviewed during the survey.

The service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings.

1. C262: A service plan team will be established on 6/17/24, consisting of the Resident Care Manager, LPN, Business Office Manager, Resident Care Coordinator, Facility Administrator, and the Cottage Captain.

2. C262: Weekly service plan meetings will be held on Wednesdays.

3. C262: The Resident Care Manager will conduct weekly monitoring.

4. C262: The Administrator will conduct weekly monitoring to ensure the service plan team is in place.

4. Resident 4 was admitted to the memory care facility in 04/2023 with diagnoses including dementia with behavioral disturbances.

Observations of the resident, interviews with staff, review of the resident's 05/29/24 evaluation and service plan, 03/01/24 through 06/03/24 temporary service plans, progress notes, physician communications, hospital discharge summaries, home health visit notes, and incident investigations were reviewed. The following was revealed:

The following short-term changes of condition lacked documentation of progress noted at least weekly, and/or documentation of resolution:

* 03/02/24: Resident-to-resident altercation;

* 03/03/24: Fall;

* 03/06/24: Fall with skin injury;

* 03/11/24: New medication;

* 03/16/24: Resident-to-resident altercation;

* 03/19/24: Resident-to-resident altercation;

* 04/01/24: Resident-to-resident altercation;

* 04/05/24: Resident-to-resident altercation;

* 04/10/24: Resident-to-resident altercation;

* 04/10/24: ER visit;

* 04/19/24: Resident-to-resident altercation;

* 04/24/24: Resident-to-resident altercation; and

* 05/22/24: Resident-to-resident altercation.

On 06/05/24 at 10:20 am, additional information was requested.

During an interview with Staff 8 (LPN) on 06/05/24 at 2:00 pm, she stated she reviewed the record and was unable to find documentation that the short term changes of condition had been monitored until resolved.

The need to ensure short term changes of condition were monitored weekly through resolution was discussed with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings. No further information was provided.  

5. Resident 3 was admitted 09/2023 with diagnoses which included dementia and diabetes.

Observations and an interview with the resident, interviews with staff, review of the service plan dated 04/08/24, incident investigations, and progress notes dated 03/01/24 through 06/03/24 were reviewed.

The following short-term changes of condition lacked documentation of progress noted at least weekly and/or documentation of resolution:

* 03/22/24: Fall;

* 03/30/24: New medication;

* 04/10/24: Resident-to-resident altercation;

* 04/23/24: Fall;

* 05/11/24: Fall; and

* 05/23/24: Fall.

In an interview on 06/05/24 at 1:55 pm, Staff 8 (LPN) reviewed the resident's record and acknowledged the findings. No further information was provided.

The need to ensure Resident 3's short-term changes of condition had documentation to reflect monitoring at least weekly to resolution Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings.

2. Resident 5 moved into the memory care community in 03/2020 with diagnoses including vascular disease.

Review of the 03/01/24 through 06/03/24 progress notes and temporary service plan, dated 05/24/24 through 05/29/24, showed  Resident 5 experienced the following short-term changes of condition:

* 03/21/24 - "Resident has a light yellow discoloration on left knee.";

* 03/28/24 - "Resident had discoloration on [his/her] left forearm and hand.";

* 05/02/24 - "Resident has 2 small discoloration spots on right knee";

* 05/10/24 - "discoloration on left arm.";

* 05/24/24 - a fall and emergency department visit;

* 05/24/24 - skin tear to the right arm and open area to back of head; and

* 05/25/24 - an emergency department visit due to pain.

The facility lacked documented evidence changes of condition were monitored, with progress noted at least weekly through resolution.

The need to ensure each of Resident 5's short term changes of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings.

3. Resident 6 moved into the memory care community in 03/2024 with diagnoses including Alzheimer's disease.

Review of the 03/21/24 through 06/01/24 progress notes and temporary service plans, dated 04/29/24 through 05/24/24, showed Resident 6 experienced the following short-term changes of condition:

* 04/16/24 - Bruising "right lower butcheek and right arm";

* 04/27/24 - Rash on the right groin area;

* 04/29/24 - Skin tear on the elbow;

* 04/30/24 - " Resident's abdomen has about a baseball sized bruise with like a road rash or rug burn on the inside.";

* 05/12/24 - " Open area on right side of buttocks";

* 05/25/24 - A fall with skin tear on the right upper elbow and left ring finger swollen;

* 05/26/24 - "Bruising/discoloration to arm and bottom"; and

* 05/27/24 - Splint on the left ring finger.

The facility lacked documented evidence changes of condition were monitored, with progress noted at least weekly through resolution.

The need to ensure each of Resident 6's short term changes of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short-term changes of condition had determined what action or intervention was needed, actions or interventions were communicated to staff on all shifts and progress was documented weekly until resolution for 5 of 6 sampled residents (#s 2, 3, 4, 5, and 6). The facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed for 1 of 4 sampled residents who experienced a significant change of condition (# 2). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 02/2023 with diagnoses including cerebrovascular accident (stroke) and dementia without behaviors.

Review of the 03/02/24 through 06/02/24 progress notes, and physician orders showed Resident 6 experienced the following short-term changes of condition:

* On 03/16/24, Staff 13 (MT) documented Resident 2 had a choking incident during a meal and his/her diet texture was downgraded from regular to mechanical soft.

* There was no documented evidence the facility determined actions or interventions and communicated to staff on each shift on swallow precautions and how staff should respond if they observed Resident 2 experiencing a choking episode.

* On 04/30/24, Staff 13 documented Resident 2 had another choking incident during a meal and his/her diet texture was downgraded to puree.

* There was no documented evidence the facility evaluated the resident, referred to the facility nurse, actions or interventions determined, documented and communicated to staff on each shift on swallow precautions and how staff should respond if they observed Resident 2 experiencing a choking episode, and the changes of condition were monitored.

The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the need to ensure there was documentation significant changes of condition were evaluated, referred to the nurse and the service plan was updated as needed, was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings. No further information was provided.  

1. C270: Facility staff received training on 6/12/24 regarding the reporting of areas/injuries of unknown origin. Staff also received training on identifying changes of condition. Service plans were subsequently updated for residents 2, 4, 5, and 6.

2. C270: The Resident Care Manager/Resident Care Coordinator will notify the LPN of all resident changes of condition.

3. C270: The LPN will notify the RN via telephone and email of any significant changes of condition.

4. C270: The Facility Administrator will conduct weekly monitoring.

Based on observation, interview, and record review, it was determined the facility failed to ensure actions or interventions were determined, documented, and communicated to staff on each shift, and interventions were monitored for effectiveness with weekly progress noted to resolution for 1 of 3 sampled residents (# 7) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:  

Resident 7 moved into the facility in 09/2022 with diagnoses including Alzheimer's disease.

During the acuity interview on 11/12/24, the resident was identified to be involved in resident to resident altercations.

Review of the resident's clinical record including progress notes from 08/12/24 through 11/11/24, the 11/01/24 service plan, and temporary service plans (TSPs) from 08/16/24 thru 10/30/24 was completed during the survey.   

a. The 11/01/24 service plan indicated the resident "has a history of altercations with other residents." Staff to redirect the resident "during times of increased behaviors by offering food, fluids, and offering other activities."

Review of the resident's clinical record, noted the resident was involved in eight resident to resident physical altercations between 08/16/24 and 11/11/24. The facility failed to determine and document what actions or interventions were needed for the repeated resident to resident altercations and failed to monitor the interventions for effectiveness.

During the survey, the resident was observed wandering throughout the facility and required staff assistance for bathroom use. Additionally, the resident needed reminders and escorting to meals and activities.

b. Review of the resident's clinical record showed the following:

* 08/18/24: On a new psychotropic medication;

* 09/12/24: A resident to resident physical altercation; and

* 09/17/24: Bruise on right thigh, buttock and scratch on left armpit area.

There was no documented evidence weekly monitoring had been completed through resolution.

During an interview on 11/13/24 at 2:58 pm, Staff 8 (LPN) confirmed the skin injury was not monitored.

The need to ensure the facility determined, documented, and communicated to staff on each shift actions or interventions that were needed, interventions were monitored for effectiveness, and weekly progress was noted until resolution for short-term changes of condition was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer) and Staff 3 (Facility RN) on 11/14/24 at 11:09 am. Staff acknowledged the findings.  

2. Resident 13 moved into the memory care facility in 08/2024 with diagnoses including dementia without behavioral disturbance and anxiety.

Review of the resident's clinical record, including progress notes, dated 01/22/25 through 04/23/25, the 03/27/25 service plan, incident reports, and Temporary Service Plans, dated 12/16/24 thru 03/28/25, were reviewed during the survey.  

The following short-term changes of condition lacked documentation the facility communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

* 01/06/25: Fall;

* 02/15/25: Open area on the left leg; and

* 03/28/25: Injury from fall resulting two abrasions and back pain.

The need to ensure the facility communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 1:50 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition were identified, actions or interventions were determined, documented, and communicated to staff on each shift, and interventions were monitored for effectiveness with weekly progress noted, through resolution, for 3 of 3 sampled residents (#s 11, 13 and 14) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 14 moved into the memory care community in 02/2025 with diagnosis including dementia with anxiety, Alzheimer's disease, vertigo, and bowel and urinary incontinence.

On 04/23/25, during the acuity interview, the resident was identified to require meal assistance and to receive hospice services.

The resident's record, including the most recent service plan, dated 02/05/25 with handwritten updates dated 03/11/25, progress notes, dated 02/05/25 through 04/24/25, and Temporary Service Plans were reviewed, observations were made, and interviews with staff were conducted. The following was identified:

a. On 02/05/25, the facility documented Resident 14's weight to be 91.5 pounds. On 03/19/25, the resident was noted to weigh 83 pounds, and indicated from the time of move-in on 02/05/25 through 03/19/25, Resident 14 experienced a total body weight loss of 8.5 pounds, or 9.28% of his/her total body weight in one month. This constituted a severe weight loss.

On 04/24/25, the following was noted:

At 10:55 am, Staff 30 (MT) stated the resident had experienced noticeable weight loss since s/he moved in, and Staff 30 was trying to obtain an order from hospice for scheduled nutritional shakes.

At 11:33 am, Staff 8 (LPN) stated since the resident was on hospice the facility was not monitoring the resident for weight loss.

At 12:19 pm, Resident 14 was observed to be assisted with meal intake by Staff 30 that included hand over hand assistance with eating and cueing the resident to initiate eating. The resident consumed approximately 75% of the meal served.

At 7:25 pm, Staff 3 (RN) stated the resident was on hospice therefore, she was not monitoring the resident's continued weight loss.

b. Behavior changes that included:

* 02/06/25: Resident 14 will "take and hide roommates" belongings;

* 02/06/25: "wanders in other resident rooms [and] goes through [their] belongings";

* 02/10/25: "will pour water on other residents";

* 02/10/25: Resident will "place self on floor";

* 02/14/25: The resident "flipped the TV";

* 02/20/25: "...resident was hitting staff and other residents...";

* 02/11/25: Exit seeking behaviors that included "...trying to get out of cottage and explained to staff escape plan...";

* 02/10/25: Resident 14 will go to the bathroom in common area;

* 02/10/25: "will take [feces] out of toilet and play with it";

* 02/12/25: The resident took a "hand full of feces [and] spread [it] all over the living room and dining room";

* 02/23/25: Insomnia;

* 02/24/25: "will take off clothes in common area and go to the bathroom on the floor";

* 02/24/25: "resident plays with [his/her] feces and will wipe on the wall";

* 03/24/25: " ...a few days ago ... [the] resident smeared feces all over another [resident's] room"; and

* 04/11/25: The resident was found out of bed and "messing with [his/her] roommate".

c. Skin conditions that included:

* 02/14/25: Skin tear to back of hand; and

* 03/17/25: "red marks on right shoulder".

The facility lacked documented evidence the changes of condition noted above were identified, and actions or interventions were determined, documented, and communicated to staff on each shift, and interventions were monitored for effectiveness, and the service plan was updated to reflect the interventions.

The need to ensure the facility evaluated, determined, documented, and communicated the determined action or intervention to staff, monitored and documented progress until resolution was reviewed with Staff 8 and Staff 29 (ED) on 04/24/25 at 6:36 pm. They acknowledged the findings.

3. Resident 11 moved into the memory care facility in 04/2023 with diagnoses including dementia and psychotic disturbance.

The resident's record, including the service plan available to staff, dated 09/23/24, Temporary Service Plans, dated 01/02/25 through 04/03/25, and progress notes, dated 01/20/25 through 04/23/25, were reviewed, observations were made, and interviews with staff were conducted.

The following short-term changes of condition lacked documented evidence the facility determined actions or interventions, communicated the determined actions or interventions to staff on each shift, and/or documented weekly progress until the condition resolved:

* Verbal resident to resident altercations occurring on 02/23/25 and 04/11/25; and

* Bruising of unknown cause on multiple dates on the resident's left or right hand.

The need to ensure the facility documented determined actions or interventions, communicated the actions or interventions to staff on each shift, and/or monitored the change through resolution was discussed with Staff 8 (LPN) and Staff 29 (ED) on 04/24/25 at 5:14 pm. They acknowledged the findings.  

1: Corrective action for Resident 14 new orders received from hospice with hospice service plan added to residents current care plan to offer and encourage eating for enjoyment without concerns for weight loss or decline in ADL's due to the terminal diagnosis. Weekly monitoring of skin issues by nursing staff.

Corrective action taken for Resident 13 correct the documentation of monitoring skin issues with adding assessment, and if needed add to weekly skin monitoring by nursing staff. Increase the documentation of intervention's and effectiveness of the interventions in place.

Corrective actions taken for residents 11 corrected with reporting bruising of unknown cause to APS and follow up with assessment by nursing staff and adding resident to weekly skin sheet. Corrective action for verbal residents to resident place new intervention during mealtimes and assess for effectiveness of interventions place.

2: The corrective action to the system for short term change of conditions, is hiring a new LPN to split the building and decrease the workload of the full time LPN in the building.

3: Checks on Short term change of conditions will be done multiple times a week during clinical review meeting.

4: Administrator or RN during clinical review will preform audits.

2. Resident 4 was admitted to the memory care facility in 04/2023 with diagnoses including dementia with behavioral disturbances.

Observations of the resident, interviews with staff, review of the resident's 05/29/24 evaluation and service plan, 03/01/24 through 06/03/24 temporary service plans, progress notes, physician communications, hospital discharge summaries, home health visit notes, and incident investigations were reviewed. The following was revealed:

A progress note and incident investigation, dated 05/08/24, indicated Resident 4 had an altercation with another resident and the other resident sustained an injury. "911 was called and resident [Resident 4] was taken to [hospital] for evaluation ..."

On 05/20/24, Staff 8 (LPN) and Staff 7 (Regional LPN) evaluated the resident in the hospital for his/her possible return to facility and "resident safety ..."

Resident 4 returned to the facility on 05/22/24 (14 days after admit to hospital).

The hospitalization constituted a significant change in condition for which an assessment by the facility RN was required.

There was no documented evidence the facility RN conducted an assessment.

During an interview with Staff 8 (LPN) on 06/05/24 at 4:30 pm, she stated the resident had been sent to the hospital because the facility was concerned for both his/her safety and the safety of other residents. She acknowledged a facility RN assessment had not been completed when the resident was readmitted back to the facility.

The facility RN was not available during the survey for interview.

The need to ensure facility RN assessments were completed with significant changes in condition was reviewed with Staff 1 (Administrator) and Staff 8 on 06/05/24 at 5:30 pm. They acknowledged the findings. No further information was provided.

3. Resident 6 was admitted to the memory care facility in 03/2024 with diagnoses including Alzheimer's disease.

Observations of the resident, interviews with staff, review of the resident's 05/09/24 evaluation and service plan, 03/21/24 through 06/01/24 temporary service plans, progress notes, physician orders and incident investigations were reviewed. The following was showed:

A progress note and incident investigation, dated 05/25/24, indicated Resident 6 had a fall which resulted in "a skin tear to right upper elbow and left ring finger, left ring finger also very swollen."

A 05/25/24 physician visit note indicated left ring finger was dislocated and required a splint on the ring finger for three weeks.

The injury represented a significant change in condition which required a facility RN assessment.

There was no documented evidence the facility RN conducted an assessment.

During an interview with Staff 1 (Administrator) on 06/05/24 at 3:30 pm, she acknowledged a facility RN assessment had not been completed when the resident had a significant injury which resulted in a major deviation of the resident's health or functional abilities.

The facility RN was not available during the survey for interview.

The need to ensure facility RN assessments were completed with significant changes in condition was reviewed with Staff 1 and Staff 8 (LPN) on 06/05/24. They acknowledged the findings. No further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 3 of 4 sampled residents (#s 2, 4 and 6) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 02/2023 with diagnoses including cerebrovascular accident (stroke) and dementia without behaviors.

Observations of the resident, interviews with staff, review of the resident's 05/01/24 service plan, progress notes, and hospice visit notes were reviewed. The following was showed:

A progress note dated 04/30/24, indicated Resident 2 had a choking incident during a meal and his/her diet texture was downgraded to puree.

This was the second choking episode and diet texture change in seven weeks and constituted a significant change in condition for which an assessment by the facility RN was required.

There was no documented evidence the facility RN had completed an assessment to include findings, resident status and interventions made as a result.

During an interview with Staff 1 (Administrator) on 06/05/24, she acknowledged a facility RN assessment had not been completed when the resident had a second episode of choking which resulted in another downgrade of diet texture to puree and constituted a significant change of condition which resulted in a major deviation of the resident's health or functional abilities.

The facility RN was not available during the survey for interview.

The need to ensure facility RN assessments were completed with significant changes in condition was reviewed with Staff 1 and Staff 8 (LPN) on 06/05/24. They acknowledged the findings. No further information was provided.

1. C280: The facility will conduct staff training on significant and short-term changes of condition.

2. C280: The LPN will communicate with the RN via email and telephone when changes of condition need to be addressed by the RN.

3. C280: The LPN will meet with the RN weekly to review resident changes.

4. C280: The Administrator will ensure that resident changes are communicated daily and weekly.     

Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 1 of 1 sampled resident (#3) who received subcutaneous injections by a facility unregulated assistive person (UAP). Findings include, but are not limited to:

Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions and outcomes pursuant OAR 851-045 including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client.

During the acuity interview on 06/03/24, Resident 3 was identified to be administered a subcutaneous injection once weekly by a facility UAP.

Resident 3's MARs from 05/01/24 through 06/03/24 revealed subcutaneous injections had been given by Staff 11 (MT/CG) and Staff 12 (MT/CG).

Review of the nursing delegation binder found no documented evidence all elements of the initial delegation were completed for Staff 11 and Staff 12.

Additionally, the RN assessment to determine Resident 3's condition was stable and predictable, one of the criteria for delegation of a nursing procedure, was not completed and/or documented.

Staff 3 (RN), the facility nurse, was not present and available during the survey.

The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 was reviewed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings. No further information was provided.

1. C282: The LPN will ensure that all RN delegations are completed in their entirety.

2. C282: The LPN/Administrator will meet with the RN to review the delegation form and add a section that explains the resident's condition as stable and predictable.

3. C282: The LPN will review the delegation binder/documents weekly and monthly, and for all new staff during orientation.

4. C282: The Administrator will follow up monthly.

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 7 and 8) and multiple unsampled residents who received dining services. Findings include, but are not limited to:

1. The surveyor observed on 11/13/24 at 12:23 pm, Staff 26 (CG) and Staff 27 (CG) serve lunch to residents in the Pine unit. There were 16 residents in the dining room for lunch. During the observations, Staff 26 and 27 donned gloves without performing hand hygiene. Staff  27 picked items including napkins from the floor and then served food to Resident 7 and other residents with the same gloves. Similarly, Staff 26 touched her hair with gloved hands multiple times and then served food without changing gloves. Staff 26 and 27 failed to change gloves between clean and dirty tasks and perform hand hygiene prior to donning gloves.  

The above observations were discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer) and Staff 3 (Facility RN) on 11/14/24 at 11:09 am. Staff acknowledged the findings.

2. The following was observed during two meal services.

a. During lunch service on 11/13/24 Resident 8 was observed to walk up to an unsampled resident and take a corn muffin from his/her plate. A caregiver observed this and redirected the resident, allowing Resident 8 to continue to eat the muffin that had been on the other resident's plate. The caregiver did not replace the unsampled resident's meal after Resident 8's fingers had been on his/her plate.

b. On 11/13/24 prior to lunch, Resident 8 was observed rubbing his/her teeth, tongue and around the inside of his/her mouth with his/her fingers. The resident then touched his/her blanket and the couch he/she was lying on in the common area. No hand hygiene was provided to Resident 8 and multiple unsampled residents prior to breakfast on 11/23/24 or lunch on 11/13/24.

The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer), Staff 3 (RN), and Staff 8 (LPN) on 11/14/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident medications were administered as ordered by the physician for 1 of 1 sampled resident (# 6) whose medication orders were reviewed. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 03/2024 with diagnoses including lactose intolerance.

Resident 6's physician orders and 08/01/25 through 09/10/25 MARs were reviewed.  

Resident 6 had an order for Lactaid Fast Act 9,000 (for lactose intolerance) to chew and swallow one tablet by mouth three times daily as needed with first bite of dairy product.

The MAR instructed staff "to check at each mealtime if dairy is being given. If yes, give PRN Lactaid Fast Act as ordered with meals for lactose intolerance."

Review of the 08/01/25 - 08/31/25 MAR showed 27 meals contained dairy. Of the 27 meals, Lactaid was administered five times.

Review of the 09/01/25 - 09/10/25 MAR showed eight meals contained dairy. Of the eight meals, there was no documented evidence Lactaid was administered.

In an interview, on 09/10/25, Staff 8 (LPN) confirmed the MAR lacked documentation that the medication was administered as ordered.

On 09/10/25, Witness 1 reported it was an ongoing struggle to have the facility administer Lactaid as ordered. Witness 1 stated they repeatedly had to remind staff that the resident required Lactaid when consuming dairy.

The need to ensure all medications were administered as ordered was discussed with Staff 2 (Chief Operating Officer), Staff 3 (Director of Nursing), Staff 10 (Admissions Coordinator), and Staff 29 (Administrator) on 09/10/25.

1.Educational guidance and counseling have been provided to the medication technicians. The relevant physician's order has been amended to require that medication technicians verify the presence of dairy in meals during their routine checks.

2.The Culinary Department shall include a clear notification on the daily menu identifying any meals that contain dairy products, in order to support dietary compliance and resident safety.

3.Menus will be subject to daily evaluation to ensure accuracy and alignment with dietary restrictions and resident care plans. Dialy clinical meeting will address that the MAR is being documented correctly.

4.The Culinary Director will be responsible for implementing and maintaining menu corrections. Oversight and follow-up will be conducted by the Facility Administrator to ensure continued compliance.

Based on interview and record review, it was determined the Administrator failed to maintain a current Residential Care Facility Administrator license. Findings include, but are not limited to:

Record review showed Staff 29 (Administrator) had been serving in the role of Administrator since 01/13/25.

On 09/12/25, the facility's policy analyst confirmed that Staff 29 serving as the Administrator, did not hold a current Residential Care Facility Administrator license.

The facility failed to have an Administrator with a current Residential Care Facility Administrator license as required.

1.As of September 22, 2025, the facility is under the leadership of a duly licensed Administrator.

2.In instances where communication challenges arise with the Health Licensing Agency (HLA), the facility shall engage the Department of Human Services (DHS) at an earlier stage to facilitate timely resolution and regulatory support.

3.The facility will ensure proactive coordination with the appropriate licensing authorities when a new license is required, including timely submission of all necessary documentation and adherence to applicable regulatory timelines.

4.Oversight and implementation of these procedures will be supported by the Management Company in collaboration with the Facility Administrator.

Based on observation, interview, and record review, it was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

The facility was divided into three memory care units: Pine, Oak, and Maple. At the time of the survey the facility was home to 53 residents: 19, 17 and 17, respectively.

The facility used the Department ABST to document resident care needs and develop its staffing plan. The data in the ABST was reviewed on 09/09/25 at 11:45 am. The facility provided a copy of the staff schedule and the time card record which included the dates and times that all staff worked for the weeks of 08/24/25 - 08/30/25 and 08/31/25 - 09/06/25. The following deficiencies were identified:

* The ABST indicated the facility needed 9 direct care staff during the day shift (6:00 am - 6:00 pm) to meet the scheduled and unscheduled needs of the residents across the three units. The facility failed to provide the required number of staff on 09/6/25 and half of the day shift on 09/03/25.

* The ABST indicated the facility needed 7 direct care staff during the night shift (6:00 pm - 6:00 am) to meet the scheduled and unscheduled needs of the residents across the three units. The facility failed to provide the required number of staff on 09/01/25 and 09/02/25.

Interviews with staff and Staff 2 (Chief Operating Officer) on 09/09/25 indicated that, though the facility scheduled the required number of staff each day on each shift, there were staff who called out and the facility was not always able to find someone to fill in on that shift.

The need to ensure the facility provided a sufficient number of staff on each shift to meet the needs of the residents was discussed with Staff 2, Staff 3 (Director of Nursing) and Staff 29 (Administrator) on 09/10/25. No additional information was provided.

1.A. Service plans have been reviewed and updated accordingly.

        B. ABST has been updated to match services provided in the residents Care Plan.

        C. Staff schedule has been updated per the ABST.

        D. Currently the ABST is requiring 3 staff in each cottege during the day. We are staffing 3 staff in each cottege with a float for added tasks.

        E. The NOC shift ABST is requiring 2 staff in each cottege. We are currently staffing 2 staff in each cottege with 2 extra staff at night.

2.A. The Aquity Based Staffing Tool (ABST) is being continuously updated to reflect current staffing levels. At present, the system indicates that each cottage is staffed with three personnel during daytime hours and two during the overnight shift.

        B. The Facility has entered into agreements with local staffing agencies to ensure adequate staff coverage and to asddress any staffing short falls.

3.The ABST will be reviewed and updated on a weekly basis, or more frequently as staffing needs evolve, to maintain accurate and compliant reporting.

4.Oversight of these staffing measures and ABST updates is the responsibility of the Facility Administrator.

Based on interview and record review, it was determined the facility failed to review the Acuity Based Staffing Tool (ABST) for each resident no less than quarterly and to use the results to develop and routinely update the facility's staffing plan. Findings include, but are not limited to:

The facility's ABST was reviewed and discussed with Staff 2 (Chief Operating Officer), Staff 1 (Administrator) and Staff 23 (Business Office Manager) on 06/04/24. The facility had implemented the ODHS ABST tool.

All three staff members confirmed the facility did not utilize the ABST for each resident no less than quarterly, to routinely update the staffing plan, nor did the ABST inform the facility the total number of weekly minutes required to meet the 24-hour scheduled and unscheduled needs of residents. Instead, the facility's staffing plan was generated by Staff 1 based on her prior work experience as a nurse.

Staff 23 stated she was scheduled to start ABST training with the Department on 06/06/24.

The need to ensure residents' ABST was reviewed no less than quarterly and the tool was used to develop and update the facility's staffing plan was discussed with Staff 1, Staff 2 and Staff 23 on 06/05/24. They acknowledged the findings. No further information was provided.

1. C361: The facility will request access to the ABST for the Resident Care Manager and the Business Office Manager.

2. C361: The facility will designate the Resident Care Manager and the Business Office Manager to complete the ABST by 8/5/2024.

3. C361: The Resident Care Manager will update the ABST daily and weekly with any changes or new move-ins.

4. C361: The Administrator will ensure compliance by 8/5/2024.

Based on interview and record review, it was determined the facility failed to ensure the ABST (Acuity Based Staffing Tool) was updated before each resident moved in, at least quarterly, and following changes of condition, to determine appropriate staffing levels to address activities of daily living and other tasks related to care, for 3 of 4 sampled residents (#s 12, 13 and 14). Findings include, but are not limited to:

a. Review of clinical records, including service plans for Residents 14, revealed the facility's ABST tool was not updated before move-in, quarterly and when there was a significant change of condition to reflect the residents' care needs, in order to ensure the ABST accurately determined the needed staffing level.

b. Review of clinical records, including service plans for Residents 12 and 13 revealed the facility's ABST tool was not updated quarterly to reflect the residents' care needs, in order to ensure the ABST accurately determined the needed staffing level.

On 04/24/25, the need to ensure the ABST tool was updated at least quarterly and following changes in condition was discussed with Staff 8 (LPN) and Staff 29 (ED). They acknowledged the findings.

1: Corrective action was to update and add the missing or incorrect hours into the system immediately upon discovery of the deficiency

2: System corrected to add a duo check system that makes sure a corrected ABST is completed with each move-in, significant change of condition and during quarterly service planning.

3: The system will be evaluated once weekly during IDT meeting.

4: The Administrator and Nursing lead will be responsible in making sure the new system remains updated with the correct information

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation for each resident was reviewed and updated no less than quarterly at the same time the resident's service plan was updated, for 2 of 2 sampled residents (#s 15 and 16) and multiple unsampled residents. This is a repeat citation. Findings include, but are not limited to:

The facility used the Department ABST to document resident care needs and develop its staffing plan. The data in the ABST was reviewed on 09/09/25 at 11:45 am. The following were identified:

a. Resident 15 was admitted to the facility in 06/2025. The resident's service plan was reviewed and updated on 09/04/25. The resident's ABST evaluation was last reviewed on 06/12/25 and was not reviewed and updated along with the service plan.

b. Resident 16 was admitted to the facility in 05/2025. The resident's service plan was last reviewed and updated on 07/16/25 but the resident's ABST evaluation was last reviewed and updated on 05/31/25.

c. Resident 5 was admitted to the facility in 03/2020. The resident's service was last reviewed and updated on 06/15/25, but the resident's ABST evaluation was last reviewed and updated on 05/31/25.

d. The date that each resident's ABST evaluation was reviewed or updated was reviewed. Of the 53 current residents reviewed, 42 resident ABST evaluations had not been reviewed and updated in the last 90 days (quarterly).

The findings were reviewed with Staff 29 (Administrator), Staff 3 (Director of Nursing) and Staff 2 (Chief operating Officer) on 09/11/25. No additional information was provided.

1.The ABST documentation has been fully updated and is current as of this reporting period. The Facility is staffing to the current ABST.

2.Daily stand-up meetings now include participation from the Service Plan Team to ensure comprehensive review and communication of:

oAny material changes to resident care plans

oCare plans currently undergoing formal review

In support of this process, the facility has implemented a centralized Excel-based tracking tool that identifies all care plan update due dates. This tool is accessible to relevant personnel and is intended to promote timely compliance and interdepartmental coordination.

3.These procedures are conducted on a daily basis during the scheduled stand-up meeting.

4.Facility Administrator  

Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months and to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

On 06/04/24, fire drill and fire and life safety records for the previous six months were requested.

Review of the documentation provided revealed there was no documented evidence the facility provided fire and life safety training for staff and conducted unannounced fire drills on alternate months.

The need to provide fire and life safety instruction to staff and conduct unannounced fire drills on alternate months was discussed with Staff 2  (Chief Operating Officer) and Staff 5 (Maintenance) on 06/04/24. They acknowledged the findings. No further information was provided.

1. C420: The facility was cited for lacking documented fire training prior to the start of the current Maintenance Director.

2. C420: The current Maintenance Director is conducting unannounced drills every other month and written training during the months without live drills.

3. C420: The Maintenance Director will evaluate and continue to conduct training and drills monthly as per the OAR.

4. C420: The Administrator will monitor compliance monthly.     

Based on interview and record review, it was determined the facility failed to ensure residents were instructed about fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 06/04/24 at 11:30 am.

There was no documented evidence residents were provided fire and life safety procedure training within 24 hours of admission to the facility and were being re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

The need for residents to be instructed about fire and life safety procedures within 24 hours of admission and at least annually thereafter, per the OFC, was discussed with Staff 2 (Chief Operating Officer) and Staff 5 (Maintenance) on 06/04/24. They acknowledged the findings. No further information was provided.

1. C422: All resident service plans will be updated to reflect the residents' ability and mental capability to participate independently in evacuations or emergency situations.

2. C422: This update will be completed at move-in and annually, as per Oregon Administrative Rule.

3. C422: The Resident Care Manager will evaluate residents at move-in and annually to ensure training is being completed.

4. C422: The Facility Administrator will monitor compliance weekly for new move-ins.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 242, C 260, C 270, and Z 164.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to C 260 and C 270.

Refer to 260,270, and 280

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to C 200, C 260, and C 363.

1. See Paln of Correction

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:

The licensee is responsible for the operation of the MCC and the provision of person-directed care that promotes each resident's dignity, independence and comfort. This includes the supervision and overall conduct of the staff.

During the third revisit survey, conducted 09/08/25 through 09/10/25, administrative oversight to ensure adequate resident care and services was found to be ineffective, as the facility remained out of compliance and continued to receive additional citations. This demonstrated an ongoing pattern of noncompliance and ineffective administrative oversight.

Refer to deficiencies in the report.  

1. Refer to C355.

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 limited to:

Refer to C 231, C 361, C 420, and C 422.

Z-142:

See Tags C231, C361, C420, C422

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 200, C 231, and C 363.

Refer to C200,C231, and C363

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are limited to:

Refer to: C 152, C 200, C 260, C 242, C 355, C 360, and C 363.

1. Refer to C152, C200, C260, C355, C242, C360, C363

Based on observation, interview, and record review, it was determined the facility failed to ensure health services were consistently provided in accordance with the licensing rules of the facility. Findings include, but are not limited to:

Refer to C 242, C 252, C 260, C 262, C 270, C 280 and C 282.

Z-162:

See Tags C242, C252, C260, C262, C270, C280, C282

Based on observation, interview, and record review, it was determined the facility failed to ensure health services were consistently provided in accordance with the licensing rules of the facility. Findings include, but are not limited to:

Refer to C 260, C 270, and C 295.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 260 and C 270.

Refer to C200, C231, C363

Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation.  Findings include, but are not limited to:

Refer to C 260 and C 303.

1. Refer to C260, C303

Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan for 2 of 6 sampled residents (#s 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

Resident 4 and 5's current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident.  

The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings.

1. Z163: The residents' service plans will be updated to reflect the specific meal plan and hydration plan by 7/30/2024.

2. Z163: The Resident Care Manager, Resident Care Coordinator, and LPN will make the updates.

3. Z163: The Facility Administrator will ensure compliance through weekly meetings until completed.

4. Z163: Facility Administrator

Based on interview and record review, it was determined the facility failed to develop individualized activity plans for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose activity plans were reviewed. Findings include, but are not limited to:

Service plans and evaluations were reviewed for Residents 1, 2, 3, 4, 5 and 6.

There was no documented evidence individualized activity plans were developed based on the residents' activity evaluations that reflected each residents' activity preferences and needs.  

The need to ensure the facility developed individualized activity plans was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 06/05/24. They acknowledged the findings.

Z-164:

See Tag C242.

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 3 of 3 sampled residents (#s 7, 8 and 9) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident service plans and activity assessments were reviewed. There was no documented evidence the facility had fully evaluated and developed individualized plans based on the residents':

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions, if necessary.

The need to ensure the facility developed individualized activity plans based on the activity evaluation was discussed with Staff 1 (Administrator), Staff 2 (Chief Operating Officer) and Staff 3 (RN) on 11/14/24. They acknowledged the findings.