Print Inspection: YMHY

The findings of the re-licensure survey, conducted 06/24/24 through 06/28/24, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

A situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause a resident serious harm. An Immediate Plan of Correction was requested in the following areas:

OAR 411-054-0027 (1): Resident Rights and Protection;

OAR 411-054-0028 (1-3): Reporting and Investigating Abuse; and

OAR 411-054-0040 (1-2): Change in Condition and Monitoring.

The facility put an Immediate Plan of Correction in place during the survey.

The findings of the first revisit to the re-licensure survey of 06/24/24, conducted 01/27/25 through 01/28/25, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 06/24/24, conducted 04/25/25, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

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 06/28/24, conducted 08/14/25, 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 and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were treated with dignity and respect, had a safe and homelike environment, and were free from neglect and sexual abuse for 1 of 1 sampled resident (#2). Resident 2 had a diagnosis of Alzheimer's disease and was involved in an ongoing sexual relationship with an unsampled resident. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 02/2024 with diagnoses including Alzheimer's disease and was unable to consent to multiple sexual interactions with another resident.

During the acuity interview on 06/24/24, Resident 2 was identified as being in an "romantic relationship" with another resident. When asked if it was a sexual relationship, Staff 4 (LPN) reported it was not. Surveyors asked if the resident had a diagnosis of dementia and, if so, had s/he been evaluated to determine his/her ability to consent to the relationship. Staff 4 stated the resident did have a dementia diagnosis, had been evaluated, and was determined to have the ability to consent to the relationship.

The resident's clinical record was reviewed, observations were made, and staff and the resident were interviewed.

In interviews with care staff on 06/24/24 and 06/25/24, the following was reported:

* The resident could become ". . . a little verbally aggressive if separated from [unsampled resident]."

* S/he had "memory issues" and had demonstrated "more confusion" recently.

* The resident had "confusion sometimes" when with the unsampled resident and became "upset when [the unsampled resident] didn't remember [him/her]."

* The ". . . majority of the time [s/he] knows who [the unsampled resident] is, but sometimes [s/he] doesn't."

* They have ". . . walked into [unsampled resident's] room and seen [him/her] sitting on the couch with [Resident 2] standing in front of [him/her] ready to take [his/her] shirt off."

Staff documented the following in the resident's progress notes:

* 05/05/24 - A MT went to the unsampled resident's room and saw the unsampled resident ". . . on [Resident 2] having sexual intimacy."

* 05/06/24 - Resident 2 was found on the bed with the unsampled resident in his/her locked bedroom, and both were naked.

* 05/09/24 - Staff 4 (LPN) completed a "Decisional Capacity Evaluation Summary." The checklist contained incomplete answers, and some questions were not answered. Staff 4 determined the resident had the capacity to consent to "intimate contact."

* 06/04/24 - A MT wrote she was unable to give Resident 2 his/her medication because s/he was, "Having sexual relations with [the unsampled] resident . . ."

* 06/11/24 - Resident 2 was angry with and afraid of the unsampled resident. After assurances from staff his/her apartment door would be locked so the unsampled resident could not enter, Resident 2 asked repeatedly if a staff member could spend the night in his/her room.

During the survey, between 06/24/24 and 06/28/24, Resident 2 was observed eating meals with the unsampled resident. On 06/25/24 the two residents were observed walking together in the hallway. They turned the corner and the surveyor started to follow them and heard a door close. When the surveyor turned the corner, the residents were no longer in the hallway. The unsampled resident's apartment was near the corner of the two hallways.

Resident 2 was interviewed on 06/26/24. The resident gave the surveyors a "tour" of her apartment twice and showed them the balcony off the living room three times within  a 10-minute period. The resident stated s/he ate meals with his/her spouse if s/he was "around." The resident's record revealed his/her spouse had moved out of the facility at the end of 05/2024. S/he stated s/he was not in an intimate relationship with the unsampled resident, wasn't sure s/he would be interested in such a relationship, and the unsampled resident had never expressed an interest in a sexual relationship.

The facility's failure to determine Resident 2's capacity to consent to a sexual relationship and failure to intervene in the sexual interactions between the two residents resulted in the loss of dignity and respect, created an unsafe environment, constituted neglect, and exposed Resident 2 to potential and ongoing sexual abuse. This resulted in a serious risk of harm to the resident.

On 06/26/24, at 3:51 pm , the survey team requested that the facility provide an immediate plan of correction. An acceptable plan of correction was received from the facility at on 06/26/24 at 5:53 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.

The need to ensure the facility honored resident rights and protected residents from neglect and abuse was discussed with Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

Refer to C 231.

1. C200 - Resident #2, to ensure resident is treated with dignity and respect and has a safe homelike environment, we have worked with both families and have moved Resident #2's relationship friend to a foster home to ensure Resident #2 is safe.

2. We will continue to monitor Resident #2 and encourage she be active in the community but not in a physical relationship with another resident.

3. We will continue to monitor to ensure she remains safe.

4. ED and Clinical team will see that the corrections are monitored.

Based on interview and record review, it was determined the facility failed to ensure incidents of abuse or suspected abuse were immediately reported to the local Seniors & People with Disability (SPD) office, failed to promptly investigate incidents of abuse or suspected abuse, and failed to take measures to protect residents and prevent the reoccurrence of abuse for 1 of 1 sampled resident (#2). Resident 2 had a diagnosis of Alzheimer's disease and was involved in an ongoing sexual relationship with an unsampled resident. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 02/2024 with diagnoses including Alzheimer's disease.

The resident's current service plan, updated 05/10/24, progress notes dated 03/25/24 through 06/19/24, temporary service plans, incident reports, and a "Decisional Capacity Evaluation Summary" dated 05/09/24 were reviewed. Staff and the resident were interviewed.

a. During the acuity interview on 06/24/24, Resident 2 was identified as being in an "romantic relationship" with another resident. When asked if it was a sexual relationship, Staff 4 (LPN) reported it was not.

Staff documented the following in the resident's progress notes:

* 05/05/24 - Resident 2 was found in the unsampled resident's room. The two residents were kissing. MT attempted to redirect Resident 2 and found the residents " ...having sexual intimacy."

* 05/06/24 - Staff found Resident 2 and the unsampled resident naked on the bed in the unsampled resident's room.

* 06/04/24 - The MT wrote she was unable to give Resident 2 his/her medication because s/he was, "Having sexual relations with resident [room number]."

* 06/11/24 - Resident 2 was angry with the unsampled resident, stating if s/he ". . . comes in here I'm going to kill [him/her]." Resident 2 stated the other resident ". . . became obsessive . . ." and ". . . im [sic] scared [s/he] knows where i [sic] live, does [s/he] know where i [sic] live?" Staff assured Resident 2 his/her apartment door would be locked so the other resident could not enter. The resident then asked multiple times, "can one of you girls [sic] stay the night on the couch and I cam [sic] stay in my room."

In interviews with care staff on 06/24/24 and 06/25/24, the following was reported:

* The resident could become ". . . a little verbally aggressive if separated from [unsampled resident]."

* S/he had "memory issues" and had demonstrated "more confusion" recently.

* The resident had "confusion sometimes" when with the unsampled resident and became "upset when [the unsampled resident] didn't remember [him/her]."

* The ". . . majority of the time [s/he] knows who [the unsampled resident] is, but sometimes [s/he] doesn't."

* They had ". . . walked into [unsampled resident's] room and seen [him/her] sitting on the couch with [Resident 2] standing in front of [him/her] ready to take [his/her] shirt off."

Resident 2 was interviewed on 06/26/24. S/he stated s/he was not in an intimate relationship with the unsampled resident, wasn't sure s/he would be interested in such a relationship, and the unsampled resident had never expressed an interest in a sexual relationship.

There was no documented evidence the sexual incidents were reported to the local SPD office, investigated to rule out abuse, or that measures were taken to protect the resident and prevent the reoccurrence of abuse. Resident 2 continued to engage in a sexual relationship with the other resident.

The facility's failure to immediately report these incidents to the local SPD office, to promptly investigate the incidents, and to take measures to protect the resident and prevent further occurrences created a serious risk of harm to the resident.

On 06/26/24, at 3:51 pm, the survey team requested the facility provide an immediate plan of correction. An acceptable plan of correction was received from the facility on 06/26/24 at 5:53 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.

The facility was requested to report the incidents to the local SPD office on 06/26/24. Confirmation of the reports was provided prior to survey exit.

The need to immediately report and promptly investigate all incidents of abuse or suspected abuse, and to protect the resident and prevent further occurrences, was discussed with Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

b. The resident's progress notes identified the following:

* 04/29/24 - The resident "attempted to throw [his/her] wine in [his/her spouse's] face" and stated, "I want a gun."

* 05/01/24 - The resident was "crying and shaky" and kept repeating "[S/he] didn't hit me but [s/he] pushed me . . ."

* 05/02/24 - Staff found broken glass on the floor of the resident's apartment, and the resident stated, "I broke it, I threw it at [him/her], I have a temper."

* 05/05/24 - The resident was outside his/her apartment crying and shaking and asked staff if they "could do more checks on [him/her] cause [s/he's] not okay." Staff documented the resident seemed "possibly frightened."

* 05/21/24 - The resident reported to staff that his/her spouse held a knife to his/her throat, and the resident's spouse confirmed this had occurred. The resident then laughed and said it was a joke. The caregiver was unable to locate a knife in the resident's apartment.

There was no documented evidence these incidents were immediately reported to the local SPD office or promptly investigated. The resident's record indicated his/her spouse had moved out of the facility the end of 05/2024.

The survey team requested that the facility report the incidents to the local SPD office. Confirmation of the reports was received prior to survey exit.

The facility's failure to immediately report and promptly investigate incidents of abuse or suspected abuse was discussed with Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

1. As mandated reporters, the staff and the clinical team have been trained on how to report to APS in regards to any type of abuse or suspected abuse immediately as required self reporters.

2. Clincial team and ED review any and all incidents daily and report and incidents of abuse or suspected abuse to prevent any future reoccurances of abuse.

3. The deficient practice will be evaulated daily by the ED and clinical team to ensure compliance.

4. ED and Nurse and LPN's will monitor.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observations of the facility kitchen and kitchenette were made on 06/24/24 from 9:00 am through 2:00 pm.

1. Observations of the facility kitchen identified the following:

a. An accumulation of food spills, splatters, loose food, and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:

* Open stainless steel shelving;

* Fan cage;

* Industrial mixer, slicer, and blender;

* Exterior of cooking appliances, refrigerators, and freezers throughout kitchen;

* Scattered walls throughout kitchen, including under shelving and counters;

* Sinks throughout kitchen;

* Coffee machine exterior;

* Juice machine exterior and underneath where juice was dispensed;

* Ice machine (interior/exterior) and filter;

* Rack across from kitchen entry;

* Trash cans throughout kitchen;

* Drains throughout kitchen;

* Carts;

* Warmer rack;

* Fryer grease trap;

* Exterior and interior of oven;

* Cooktop and grill;

* Stainless steel backsplash behind cooktop;

* Fans in walk-in refrigerator;

* Floors under racks and equipment;

* Floors in walk-in refrigerator and freezer;

* Floor drainage sink with heavy dark sediment in room labeled "Janitor Kitchen Only"; and

* Cabinet under the sink in the dining room had soiled washcloths and debris.

b. The following needed repair or replacement:

* Cutting board on service line was stained and scored, which created an uncleanable surface.

c. Industrial mixer, slicer, and blender were uncovered when not in use.

d. Caregivers were not wearing aprons when serving food to residents.

e. The fan had dust on the cage which was blowing air over the food prep area.

f. Trash can next to the kitchen entry was uncovered during non-prep times.

h. Walk-in refrigerator and walk-in freezer had several food items uncovered, not dated, and/or with no "use by" date indicated.

i. Two food items in the dry storage were open, with no "use by" date indicated.

2. Observations of the facility kitchenette identified the following:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:

* Stainless steel shelving;

* Reach-in refrigerator interior/exterior;

* Sinks;

* Drains;

* Cart;

* Warming plates;

* Toaster;

* Ice machine exterior; and

* Overhead vent.

b. The following areas observed in the kitchenette needed repair or replacement:

* Cutting board on service line was stained and scored, which created an uncleanable surface; and

*Stained ceiling tiles.

c. Ice machine in the kitchenette had a scoop directly on the ice.

d. Refrigerator in the kitchenette contained three unlabeled juice pitchers.

e. Kitchenette freezer contained open packaging and unlabeled chicken.

On 6/25/24 the areas above were reviewed with Staff 21 (Director of Culinary Services) and Staff 1 (Director of Operations/Interim Administrator). They acknowledged the findings.

1. The kitchen has been thoroughly cleaned and the following items have been addressed. All items idenified from list under C240 have been addressed accordingly.

In regards to the items needing repair and or replacement, all listed items have been addressed and are now in compliance. All food items in dry storage that are currently opened have been disposed of and new food items opened will be dated on date of opening and with a use by date noted.

2. We will add this to our monthly CQI process to identify areas that need attention.

3. and 4. Director of Culinary Services will monitor all areas daily and Executive Director will confirm weekly.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and/or provided clear direction to staff for 1 of 2 sampled residents (#1), whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 moved into the facility in February 2024 with diagnoses including dementia and chronic ulcer of left foot.

The resident's current service plan, dated 04/08/24, was reviewed, observations were made, and interviews with staff were conducted. Resident 1's service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Preference for sleeping in recliner;

* Activity preferences, including watching TV;

* Refusal of care and interventions for refusals;

* Level of assistance required with bathing;

* Level of assistance required with dressing;

* Level of assistance required with transferring from recliner;

* Level of assistance required with ambulation; and

* Call light use ability.

The need to ensure service plans reflected the residents' needs and provided clear direction to staff was discussed with Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

1. Resident #1 has since moved out of the community.

For existing residents, service plans have been reviewed and updated accord to residents personal preferences, level of assistance with ADL's, and clear direction to staff has been discussed and added to task lists for all care team.

2. DRS and licensed nurses will monitor to ensure service plans and task lists are updated according and that the care team has reviewed, after each service plan review and as needed.

3. This will be added to our monthly CQI process and reviewed by all clincial team, and ED monthly.

4. Clinical team and ED are responsible.

Based on observation, interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the RN when needed, interventions were determined, documented, communicated to staff, and implemented, and interventions were monitored for effectiveness for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Resident 2 had an ongoing sexual relationship with an unsampled resident. Resident 1 experienced a fall resulting in a clavicle fracture following multiple falls without interventions or monitoring. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 02/2024 with diagnoses including Alzheimer's disease.

The resident's current service plan, updated 05/10/24, progress notes dated 03/25/24 through 06/19/24, temporary service plans, incident reports, and a "Decisional Capacity Evaluation Summary" dated 05/09/24 were reviewed. Staff and the resident were interviewed.

a. During the acuity interview on 06/24/24, Resident 2 was identified as being in an "romantic relationship" with another resident. When asked if it was a sexual relationship, Staff 4 (LPN) reported it was not.

Staff documented the following in the resident's progress notes:

* 05/05/24 - A MT went to the unsampled resident's room and saw the unsampled resident ". . . on [Resident 2] having sexual intimacy."

* 05/06/24 - Resident 2 was found on the bed with the unsampled resident in his/her locked bedroom, and both were naked.

* 05/09/24 Staff 4 (LPN) completed a "Decisional Capacity Evaluation Summary." The checklist required "yes" or "no" answers to eleven questions, with an area for "comments" after each question. The following questions were left blank:

- Cognitive score (MMSE) greater than 14?; and

- Does the resident have the capacity to avoid exploitation?

Multiple questions lacked narrative in the "comments" section, or had answers recorded from the resident interview that did not indicate consent. These included, but were not limited to:

- "How does the current behavior of the resident correlate with the residents [sic] past beliefs and actions (as known by residents or others)? was marked as "yes," with no further narrative.

- "Is the resident aware of the relationship?" was marked "yes," with the word "Acquaintance" in the comments section.

- "Is the resident's concept of who the relationship is with consistent with reality?" was marked "yes." Comments indicated the resident stated, "I will never do it again, my husband is with me."

Staff 4 determined the resident had the capacity to consent to "intimate contact," and documented in the "Comments regarding pivotal factors driving outcome of evaluation:" section: "Family notified of residents [sic] eval."

There was no further documented evidence of a complete evaluation to determine the resident's capacity to consent to a sexual relationship with another resident.

* 06/04/24 - A MT wrote she was unable to give Resident 2 his/her medication because s/he was, "Having sexual relations with [the unsampled] resident . . ."

* 06/11/24 - Staff documented Resident 2 was angry with and afraid of the unsampled resident. After assurances from staff his/her apartment door would be locked so the unsampled resident could not enter, Resident 2 asked repeatedly if a staff member could spend the night in his/her room.

During the survey, between 06/24/24 and 06/28/24, Resident 2 was observed eating meals with the unsampled resident. On 06/25/24 the two residents were observed walking together in the hallway. They turned the corner and the surveyor started to follow them and heard a door close. When the surveyor turned the corner, the residents were no longer in the hallway. The unsampled resident's apartment was near the corner of the two hallways.

Resident 2 was interviewed on 06/26/24. The resident gave the surveyors a "tour" of his/her apartment twice and showed them the balcony off the living room three times within  a 10-minute period. The resident stated s/he ate meals with his/her spouse if s/he was "around." The resident's record revealed his/her spouse had moved out of the facility at the end of 05/2024. S/he stated s/he was not in an intimate relationship with the unsampled resident, wasn't sure s/he would be interested in such a relationship, and the unsampled resident had never expressed an interest in a sexual relationship.

There was no documented evidence the facility completed a full evaluation to determine the resident's ability to consent, monitored the resident's change in behavior, or re-evaluated the resident when s/he expressed anger toward and fear of the unsampled resident. In addition, there was no documented evidence the facility developed interventions to ensure the resident had no further sexual contact with the unsampled resident after expressing fear of the unsampled resident.

The facility's failure to evaluate the sexual incidents between Resident 2 and the unsampled resident and to determine actions or interventions, document and communicate the actions or interventions with staff on all shifts, and to monitor interventions for effectiveness created a serious risk of harm to the resident.

On 06/26/24, at 3:51 pm, the facility was requested to provide an immediate plan of correction. An acceptable plan of correction was received from the facility on 06/26/24 at 5:53 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.

The need to ensure changes in residents' behaviors were evaluated, actions or interventions were determined, documented, communicated to staff on all shifts, and implemented, and ensure interventions were monitored for effectiveness was discussed with Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

b. The resident's progress notes identified the following:

* 04/29/24 - The resident "attempted to throw [his/her] wine in [his/her spouse's] face" and stated, "I want a gun."

* 05/01/24 - The resident was "crying and shaky." The resident's spouse was packing, saying s/he was leaving. "Resident kept repeating "[S/he] didn't hit me but [s/he] pushed me . . ."

* 05/02/24 - Staff found broken glass on the floor of the resident's apartment, and the resident stated, "I broke it, I threw it at [him/her], I have a temper."

* 05/05/24 - The resident was outside his/her apartment crying and shaking and asked staff if they "could do more checks on [him/her] cause [s/he's] not okay." Staff documented the resident seemed "possible frightened."

* 05/21/24 - The resident reported to staff that his/her spouse held a knife to his/her throat, and the resident's spouse confirmed this had occurred. The resident then laughed and said it was a joke. The caregiver was unable to locate a knife in the resident's apartment.

There was no documented evidence these incidents were evaluated or that actions or interventions were determined, documented, communicated to staff on all shifts, and implemented.

The facility's failure to evaluate changes in the resident's behavior, determine actions or interventions, and monitor interventions for effectiveness was discussed with Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

2. Resident 1 moved into the facility in February 2024 with diagnoses including dementia and chronic ulcer of left foot.

The resident's service plan, Temporary Service Plans (TSPs), progress notes dated 03/26/24 through 06/24/24, and incident reports were reviewed during the survey.

Resident 1's 04/08/24 service plan indicated the resident was at risk for falls due to dementia diagnosis and was on safety checks every "2 to 3 hours."

* On 04/26/24 the resident experienced an unwitnessed fall in a common area, hitting his/her head, and was sent to the hospital.

On 05/01/24 the facility RN documented in a progress note that she went to the hospital to assess the resident; however, the resident was asleep during the visit. The RN also documented  "[Resident] is a stand-by-assist with mobility, transfers, and ADLs."

On 05/02/24 the resident returned to the facility. There was no evidence the facility investigated the root cause of the fall on 04/26/24 or developed interventions to help prevent future falls.

The resident's record indicated Resident 1 had subsequent falls on the following dates:

* On 05/21/24 the resident experienced an unwitnessed fall in his/her room, stating s/he hit his/her head and that his/her back hurt.

* On 05/25/24 the resident experienced an unwitnessed fall in his/her room, with bruising on his/her chin.

* On 06/11/24 the resident experienced an unwitnessed fall in his/her room with "welt on left side of [his/her] head" and was sent to the hospital.

There was no documented evidence the facility investigated the root cause of the falls, developed resident-specific interventions to help minimize future falls, reviewed previously service-planned interventions for effectiveness, or monitored the resident's condition after each fall.

The facility's failure to evaluate the resident after each fall, determine actions or interventions, communicate the interventions to staff, and monitor the interventions according to the needs of the resident, put the resident at risk for repeated falls and serious injury.

On 06/13/24 the resident returned to the facility with a diagnosis of a broken clavicle. There was no documented evidence the facility evaluated the resident, updated the service plan related to increased care needs as a result of the broken clavicle, or monitored the resident according to his/her evaluated needs.

During an interview on 06/28/24, Staff 3 (LPN) reported the interventions for the resident's falls were safety checks every 2-3 hours, physical therapy, and "we are talking about getting a chair alarm." She acknowledged the interventions were not being monitored to determine effectiveness.

During the survey, multiple caregivers indicated they were not sure how often Resident 1 required safety checks. On 6/28/24 a caregiver showed the surveyor the electronic task list for Resident 1 and safety checks were not listed.

Throughout the survey, staff were observed checking on the resident frequently and providing stand-by assist with all transfers, ambulation, and ADL care.

The need to ensure residents who experienced a change of condition were evaluated and resident-specific actions or interventions were developed, communicated to staff, and monitored through resolution was discussed with Staff 2 (Regional Director of Clinical Services) and Staff 3 on 06/28/24. They acknowledged the findings.

1. Resident #1 no longer resides in the community. Resident #2's change of condition has been evaluated by the RN, intervention was completed by moving her male companion out of the community. ED, and clinical team will continue to monitor Resident #2 to ensure she does not engage in another physical relationship.   Her service plan has been updated to reflect current needs.

2. RN has been trained and educated on completing change of condition and monitoring residents and making necessary change of conditions regarding falls, resident to resident altercations. Residents will be elevated to determine the ability to consent to sexual relationships for residents with dementia diagnosis.

3. Clinical review will take place weekly and added to our CQI process monthly.

4. Licensed clinical team and Executive Director.

2. Resident 2 was admitted to the facility in 02/2024 with diagnoses including Alzheimer's disease.

A review of the resident's clinical record, including progress notes dated 03/25/24 through 06/19/24 and weight records dated 03/03/24 through 06/01/24, was completed, and staff were interviewed. The following was identified:

* 04/01/24 - 111.4 pounds; and

* 05/02/24 - 105.2 pounds.

The resident experienced a weight loss of 6.2 pounds, or 5.6% of his/her total body weight, in one month. This was considered a severe weight loss and a significant change of condition.

There was no documented evidence an RN assessment was completed for the resident's weight loss.

Between 05/02/24 and 06/01/24, the resident's weight fluctuated between 103 and 109.2 pounds. On 05/20/24 the facility RN faxed the resident's physician to inform him of the weight loss. There was a physician order dated 05/22/24 for the resident to be weighed daily until his/her appointment with the physician on 05/29/24 and a physician order dated 05/29/24 for one Ensure (supplemental health shake) three times a day.

The facility RN was unavailable for interview during the survey.

On 06/25/24 Resident 2 was observed to eat less than 50% of his/her lunch and drank 100% of his/her health shake. On 06/26/24, Staff 15 (Server) reported the resident ate 25% of his/her breakfast and drank 100% of his/her health shake.

The surveyor requested the resident be weighed on 06/26/24. On 06/28/24 the facility provided weights taken on 06/27/24 and 06/28/24: 102 pounds and 103 pounds, respectively.

RN weight logs were reviewed on 06/27/24 with Staff 2 (Regional Director of Clinical Services). Although there were multiple and highlighted entries, there was no indication Resident 2's weight was being monitored. Staff 2 was unable to determine the facility's process for monitoring weights and determining significant changes.

The need for an RN to complete an assessment of all significant changes of condition in a timely manner was discussed with Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN significant change of condition assessment was completed following significant changes of condition for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 02/2024 with diagnoses including dementia and chronic ulcer of the left foot.

A review of the resident's clinical record, including progress notes dated 03/26/24 through 06/24/24, weight records dated 02/05/24 through 06/21/24, and RN weight logs, was completed, and staff were interviewed.

a. On 06/11/24 the resident experienced a fall, hitting his/her head, and was sent to the hospital. The resident returned from the hospital on 06/13/24 with a diagnosis of a fractured clavicle.

An "RN Significant Change of Condition" document dated 06/13/24 stated: "[Resident] fell 6/11 and hit [his/her] head. [S/he] was transported to [hospital] and diagnosed with a clavicle fx. [Resident] has scheduled toileting every 2 hours and safety checks every 2-3 hours. Will continue to monitor weekly at this time."

During the survey, the resident was observed wearing a sling on his/her left arm. Staff reported the resident had been wearing this since his/her clavicle fracture.

There was no evidence the resident was assessed according to his/her needs after the clavicle fracture, including changes in ADL assistance, interventions developed based on the assessment, and the service plan updated.

b. Resident 1's weight records identified the following:

* 03/01/24 - 103.8 pounds;

* 04/03/24 - 97.2 pounds; and

* 06/07/24 - 94.0 pounds.

Between 03/01/24 and 04/03/24 the resident experienced a weight loss of 6.6 pounds, or 6.4% of his/her total body weight, in one month. This was considered a severe weight loss and a significant change of condition.

Between 03/01/24 and 06/07/24 the resident experienced a weight loss of 9.8 pounds, or 9.4% of his/her total body weight, in three months. This was considered a severe weight loss and a significant change of condition.

There was no documented evidence an RN assessment was completed for the resident's weight loss.

The facility RN was unavailable for interview during the survey.

RN weight logs were reviewed on 06/26/24 with Staff 2 (Regional Director of Clinical Services). Although there were multiple and highlighted entries, Staff 2 was unable to determine the facility's process for monitoring weights and determining significant changes of condition.

Resident 1 ate 100% of the three meals observed during the survey. A current weight was requested on 06/26/24. The resident weighed 97.7 pounds.

The need for an RN to complete a timely assessment of all significant changes of condition was discussed with Staff 2 and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

The need for an RN assessment for significant changes of condition was discussed with Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

1.Resident #1 has since moved out of community.

Resident #2 weight loss has been addressed and doctor has been notified, and is currently being offered Ensure 3 times daily. Family has been made area of current weight condition as well. Service Plan has been updated and a significant change assessment has been completed by the RN.

2. RN and clinical team are monitoring weights, double checking weights to ensure they are correct. RN is completing a significant change of conditon related to weight loss and funtional decline, reporting to family and doctor. LPN, RN have all trained and educated on significant change assessments and understand the process going forward to ensure correct systems are being ulitized.

3. Clinical team will have weekly at risk meetings to identify the need for significant change assessments and will complete accordingly. Significant change assessments will be added to our monthly CQI.

4. The RN, DRS and ED will be responsible for monitoring.

Based on interview and record review, it was determined the facility failed to ensure there were written, resident-specific parameters for PRN psychotropic medication and that non-pharmacological interventions were attempted and documented as ineffective prior to PRN psychotropic medication being administered for 2 of 2 sampled residents (#s 2 and 3) whose MAR and physician orders were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 02/2024 with diagnoses including Alzheimer's disease.

Review of the resident's 06/01/24 through 06/24/24 MAR, current physician orders, and 03/25/24 through 06/19/24 progress notes identified the following:

* Resident 2 had a signed physician order for lorazepam 0.5 mg, one tablet by mouth every 12 hours as needed for agitation;

* There were no resident-specific parameters or non-pharmacological interventions;

* The resident was administered the PRN lorazepam on 06/01/24; and

* There were no non-pharmacological interventions documented in the resident's chart as having been attempted and ineffective prior to the PRN lorazepam being administered on 06/01/24.

The need to have written, resident-specific parameters for PRN psychotropic medications, and to document non-pharmacological interventions attempted and ineffective prior to administration of a PRN psychotropic, was discussed with Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 01/2021 with diagnoses including Parkinson's disease and anxiety disorder.

Review of the resident's 06/01/24 through 06/24/24 MAR and current physician orders identified the following:

* The resident had a signed physician order for alprazolam 0.5 mg, one tablet by mouth three times a day as needed for anxiety, with non-pharmacological interventions including offering to sit and do one-on-one conversation and offering breathing exercises;

* Alprazolam was administered to the resident on nine occasions between 06/01/24 and 06/24/24;

* The reason for use for the PRN psychotropic (anxiety) was not documented;

* The non-pharmacological interventions prescribed were not documented; and

* There was no documented evidence non-pharmacological interventions had been attempted and were ineffective prior to administration of the PRN alprazolam.

The need to have resident-specific parameters and non-pharmacological interventions for all PRN psychotropic medications, as well as the need to attempt non-pharmacological interventions and document them as ineffective prior to administering a PRN psychotropic, was discussed with Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

1. For the two sampled residents 2 and 3 along with remaining residents that have orders for psycotropic medications, orders have been reviewed by pharmacist and med staff will be educated on use and documentation on MAR of non-pharmacologic interventions prior to administration of psychotropic medications. Resident non-pharmacologic interventions will be initiated and documented as effective/ineffective on MAR prior to administration of psychotropic administration if previous inteventions non-sucessful.

2. Resident non-pharmacological interventions will be initiated and documented as effective/ineffective on MAR prior to administration of psychotropic medications.

3. Non-pharmacological interventions and psychotropic medication review will take place monthly as part of CQI process and reviewed by DRS, ED and clinical team for compliance.

4. ED, DRS, and Clinical Team will monitor current  process.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 7, 8, 11, and 16) completed all required pre-service orientation and dementia training prior to beginning their job responsibilities and providing care for residents and failed to ensure 1 of 3 long-term non-care staff completed the required Home and Community Based Services (HCBS) training. Findings include, but are not limited to:

Staff training records were reviewed on 06/27/24 and revealed the following:

a. There was no documented evidence Staff 7, Staff 8, Staff 10, or Staff 16, all CGs, hired 03/08/24, 03/15/24, 03/15/24, and 05/20/24, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities:

* Abuse reporting requirements;

* Fire safety and emergency preparedness;

* Written job description;

* Infectious disease prevention; and

* Approved HCBS course.

b. There was no documented evidence Staff 7, Staff 11, or Staff 16 had completed one or more of the following pre-service dementia care training topics:

* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;

* Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics;

* Strategies for addressing social needs and engaging them in meaningful activities; and

* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach.

c. There was no documented evidence Staff 19 (Server), hired 04/15/22, had completed the required HCBS training by 03/31/24 as required.

The need for staff to complete all required pre-service orientation and dementia training prior to starting their job duties and providing care to residents, and for all non-care staff to complete HCBS training, was discussed with Staff 6 (Office Manager) on 06/27/24 and Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

1. Office Manager and ED audited all employee files and had Staff 7, 8, 11, 16 and 19 complete all orienatation, and pre-service dementia training and HCBS training.

2. All new hires will be required to complete all state required trainings prior to working within the community.

3. Upon each new hire the OM and ED will audit to insure compliance. New hire checklists will be completed and signed off by all parties.

4. Office Manager, Executive Director and DRS will be responsible to see that corrections are completed and monitored going forward to stay within state compliance.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired staff (#26) completed all required pre-service orientation training prior to beginning their job responsibilities and providing care for residents. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 01/28/25 and revealed the following:

Training records for Staff 26 (Activities Assistant), hired 11/20/24, identified the following:

Staff 26 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of:

* Abuse reporting requirements;

* Fire safety and emergency preparedness;

* Infectious disease prevention; and

* Approved Home and Community-Based Services (HCBS) course.

The requirements for pre-service orientation and training for all employees prior to starting their job duties was discussed with Staff 23 (Office Manager), and Staff 22 (Director of Resident Services) 01/28/25. They acknowledged the findings.

1. All required pre-service orientation and trainings of all employees prior to starting their job duties will be completed upon hire.

2. Checklist has been implemented in all employee files to ensure they are compliant.

3. Upon each new hire, 30-day after hire and annually on required renewed training.

4. Office Manager and Director of Resident Services, signed off by

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 28 and 32) completed all required pre-service orientation training prior to beginning their job responsibilities and providing care for residents. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 04/25/25 and revealed the following:

Training records for Staff 28 (CG), hired 04/22/25, and Staff 32 (Med Tech), hired 04/02/25, identified the following:

a. Staff 28 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of:

* Abuse reporting requirements;

* Fire safety and emergency preparedness; and

* Approved LGBTQIA2S+ course.

b. Staff 32 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of:

* Resident right and values of CBC care;

* Abuse reporting requirements;

* Fire safety and emergency preparedness;

* Approved Home and Community-Based Services (HCBS) course; and

* Approved LGBTQIA2S+ course.

The requirements for pre-service orientation and training for all employees prior to starting their job duties was discussed with Staff 4 (Director of Resident Services), and Staff 27 (ED) on 04/25/25. They acknowledged the findings.

1. Staff #28 and #32 will have all trainings completed by 5/25/25. Direct-care staff training will be audited to ensure  that required training (elder abuse, fire safety/emergency preparedness, LBGTQIA2S+, resident rights, home and community based services (HCBS), infection control, pre-service dementia care, first aid including abdominal thrust) as well as a review of their written job description are competed prior to providing care to residents.

2. All required staff, including direct-care staff training has been audited to ensure that required training (elder abuse, fire safety/emergency preparedness, LBGTQIA2S+, resident rights, infection control, home and community based services (HCBS), first aid including abdominal thrust) as well as a food handling course if duties include preparing food and a review of their written job description are completed prior to beginning their job responsibilities.

3. An on boarding course checklist is to be signed off by a trainer prior to new employees beginning their job responsibilities and direct-care staff providing care to residents.

4. Tracking sheet with all employee's will be monitored monthly to ensure all are current.

5. Executive Director, Director of Resident Services and Office Manager.   

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 7, 8, 10, and 16) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 06/27/24 and revealed the following:

There was no documented evidence Staff 7 (CG), Staff 8 (CG), Staff 10 (MT), or Staff 16 (CG), hired 03/08/24, 03/15/24, 11/21/23, and 05/20/24, respectively, demonstrated competency in all assigned job duties within 30 days of hire in one or more of the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation, and reporting of changes of condition;

* Conditions which require assessment, treatment, observation, and reporting;

* General food safety, serving and sanitation;

* Other duties as applicable (med pass, treatments); and

* First aid/abdominal thrust.

The need for staff to demonstrate competency in their assigned job duties within 30 days of hire was discussed with Staff 6 (Office Manager) on 06/27/24 and Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

1. All staff files have been audited for missing required training components. Staff 7, 8, 10 and 16 have been retrained to demonstrate competency in all assigned job duties with a mentor.  

2. All new hires will be required to completed all state required trainings prior to working within the community and be required to demostrate competency of their job duties within 30-days of hire.

3. Upon each new hire the OM and ED will audit to insure compliance, along with a new hire checklists will be completed and signed off on by all parties.

4. Office Manager, Executive Director and DRS will be responsible to see that corrections are completed and monitored going forward to stay within state compliance.

Based on interview and record review, it was determined the facility failed to ensure and document 3 of 3 long-term staff (#s 13, 17, and 18) completed 12 hours of annual in-service training, including at least six hours of dementia care and one hour of infectious disease training, and failed to ensure 2 of 2 long-term non-care staff (#s 9 and 14) completed infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed on 06/27/24 and revealed the following:

a. There was no documented evidence Staff 13 (CG), Staff 17 (CG/MT), and Staff 18 (CG), hired 08/17/22, 06/11/21, and 04/06/22, respectively, completed at least 12 hours of training related to the provision of care in CBC, including a minimum of six hours of training on dementia care topics and at last one hour of infectious disease training.

b. There was no documented evidence Staff 9 (Server), hired 12/19/22, or Staff 14 (Cook), hired 09/30/22, completed infectious disease training.

The need to ensure and document that long-term direct care staff completed the required number of hours of annual in-service training and that long-term non-care staff completed annual infectious disease training was discussed with Staff 6 (Office Manager) on 06/27/24, and Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

1. All staff files will be audited for missing required training components. Staffing 13,17,18 have completed their 12 hours of annual in-service training, including 6 hours of dementia care and one hour of infectious desease training, and how long-term noncare Staff 9 and 14 have also completed infectious disease training.

2. All hires will be required to completed their annual in-service training. DRS, (Office Manager, and ED will track each employees on boarding training along with their annual in-service training to ensure all training requirements are met.

3. Upon each new hire the OM and ED will audit to insure compliance, along with a new hire checklists will be completed and signed off on by all parties.

4. Office Manager, Executive Director and DRS will be responsible to see that corrections are completed and monitored going forward to stay within state compliance

Based on interview and record review, it was determined the facility failed to ensure a system was in place to ensure all direct care staff completed a minimum of 16 hours of inservice training annually, and failed to ensure 1 of 2 long-term non-direct care staff (#19) completed annual Home and Community-Based Services (HCBS) training. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed, and interviews with staff were conducted on 01/28/25 and revealed the following:

a. During an interview at 11:15 am on 01/28/25, Staff 23 (Office Manager) was asked to explain the facility's process for providing annual in-service training to staff. Staff 23 stated the facility's goal was to assign courses through an online training program and the facility would monitor the courses and hours of training completed by staff. Staff 23 stated this had not been initiated yet.

b. There was no documented evidence Staff 19 (Cook), hired 09/30/22, completed required HCBS training.

The need to ensure a system was in place to ensure all direct care staff completed a minimum of 16 hours of inservice training annually, and that long-term non-direct care staff completed HCBS training was discussed with Staff 23 and Staff 22 (Director of Resident Services) on 01/28/25. They acknowledged the findings.

1. New annual and biennial inservice training checklist have been implemented for all employees with Oregon Care Partner trainings.

2. Upon hire, trainings will be implemented and verified and confirmed completion as required on pre-service trainings, within 30-days trainings and annual and biennial trainings.

3. On-going, upon hire onboarding orientation, within 30-days of hire, biennial and annually.

4. Office Manager, Director of Resident of Services, and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure a system was in place to ensure all direct care staff completed a minimum of 12 hours of in-service training annually, and failed to ensure 2 of 2 long-term direct care staff (#s 17 and 18) and 1 of 1 long-term non-direct care staff (# 33) completed annual infectious disease training and Home and Community-Based Services (HCBS) training. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed, and interviews with staff were conducted on 04/25/25 and revealed the following:

1. During an interview at 3:52 pm on 04/25/25, Staff 27 (ED) was asked to explain the facility's process for providing annual in-service training to staff. Staff 27 stated the facility's goal was to assign courses through an online training program and the facility would monitor the courses and hours of training completed by staff. Staff 27 stated this had not been fully implemented yet.

2. Staff training records were reviewed on 04/25/25 and revealed the following:

a. There was no documented evidence Staff 17 (CG/Med Tech), hired 06/11/21 and Staff 18 (CG), hired 04/06/22, completed required annual infectious disease training and HCBS training.

b. There was no documented evidence Staff 33 (Server), hired 07/01/22, completed required annual infectious disease training and HCBS training.

The need to ensure a system was in place to ensure all direct care staff completed a minimum of 12 hours of inservice training annually, and that long-term direct care and non-direct care staff completed annual infectious disease training and HCBS training course was discussed with Staff 4 (Director of Resident Services) and Staff 27 (ED) on 04/25/25. They acknowledged the findings.

1. System has been put in place to ensure all direct care staff complete a minimun 12 hours of in-service training annually, including that long-term direct care and non-direct care staff complete annual infectious disease training an HCBS training.

2. Tracker has been put in place to monitor and track each employees completion of course and/or due for trainings.

3. Tracker will be updated upon new hires, terminations, and annual biennial due dates for all staff onboarding of.

4. Executive Director, Director of Resident Service, and Office Manager.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to consistently provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:

Fire and life safety records were reviewed with Staff 5 (Director of Plant Operations) on 06/25/24.

The facility provided documentation of one fire drill in the last six months, conducted on 03/29/24. Staff 5 reported he was not aware he needed separate fire drills for the two facility licenses in the building.

The need to conduct fire drills every other month and provide fire and life safety instruction to staff on alternate months was discussed with Staff 5 on 06/25/24 and with Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

1. Staff #5 (Director of Maintenance) has been educated of the requirements per licensing for each side of the building and will conduct fire drills every other month and provide fire and life safety instruction to staff and residents on alternate months.

2. Fire and Safety binders will be audited monthly as apart of our CQI process to insure compliance.

3. Monthly.

4. Managed by Maintenance Director and Executive Director for compliance.

Based on interview and record review, it was determined the facility failed to re-instruct residents 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. Findings include, but are not limited to:

On 06/27/24 the surveyor discussed the facility's process for instructing residents on fire safety procedures with Staff 5 (Director of Plant Operations).

Staff 5 reported he did not currently have a system for re-instructing residents annually on fire and life safety procedures.

The need to develop a process for re-instructing residents at least annually on fire safety procedures was discussed with Staff 5 on 06/27/24 and with Staff 2 (Regional Director of Clinical Services) and Staff 3 (LPN) on 06/28/24. They acknowledged the findings.

1. Staff #5, Director of Maintenance has been trained on the requirements per licensing for both AL an MC and will conduct fire drills monthly and evacation methods. Staff #5 has to re-instructed all residents in ALF and MC in general safety procedures. Staff #5 will have residents sign or note name of resident that as they attend. Staff #5 will note and instruct on the designated meeting place outside or within the fire safe area in event of an actual fire. Staff #5 will provide fire and life safety instruction to staff and residents on alternate months.

2. Staff #5 has corrected they system failure to and has ensured all residents are re-instructed and will continue to re-instruct current residents annually. Fire and Safety binders will be audited monthly as apart of our Quality process to ensure compliance.

3. Monthly.

4. Managed by Maintenance Director and Executive Director for compliance.Re

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 370 and C 374

1. C370, C372 will be corrected and satisified by March 14, 2025.

2. Tracking of all trainings and process and procedures are being documented and filed in each employees.

3. Training upon new hire and again within 30-days of hire and annually thereafter.

4. Office Manager keeping tracker updated, Alderbrook Director confirming training is completed, Director of Residents Service to oversee, and Executive to sign off.

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

Refer to C 370 and C 374.

1. Executive Director and Director of Resident Service are taking immediate action to ensure inspection and investigation is in compliance by May 25th, and continue compliant going forward.

2. Tracking systems are being put in place to ensure training are in compliance at all times.

3. Upon new onboarding of employees, monthly and ongoing to ensure always in timely and current.

4. Executive Director, Director of Resident Services, and Office Manager.