Firwood Gardens RCF

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

The findings of the kitchen inspection, conducted date through date, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, OARs 411 Division 57 for Memory Care Communities, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 07/22/25 at 11:30 am, the kitchen was observed. The following was identified: a. A build-up of dust, dirt, food splashes/debris, black matter, and grease was observed on the following: * The commercial can opener; * The walls, floors, baseboards, and ceilings throughout the kitchen; * The interior of storage drawers; * The exterior of the ice maker; * The exterior and underneath “Fridge 1” by the grill; * The metal bread cart; * The exterior of the flour and sugar bins in dry storage; * The legs of stainless steel shelving/sinks/prep surfaces; * Food/beverage carts including the rubber bumpers of the dirty dish cart to the right of the dishwashing area; and * Interior and fronts of open shelving in beverage area; b. The following was in need of repair: * Peeling paint observed around ceiling vents; * Peeling tape observed on countertops and fronts in beverage and hot food pass area; * Multiple cabinet tops and fronts had chips, dings, scratches and laminate coming off, rendering their surfaces uncleanable; * Pieces of tile baseboard were missing near “Fridge 1”; and * Paint was chipped off the corners of the walls in multiple areas of the kitchen. c. The following improper food storage/handling practices were observed: * Staff were observed delivering food and beverages to residents on the second floor. The ice bucket on the beverage tray was not covered to prevent contamination during transport; * Staff were observed scooping ice from the bucket with a water cup with their bare hands rather than using a scoop with a handle; and * Scoops for flour and baking soda were stored directly in the bins. The kitchen was toured and the above was discussed with Staff 2 (Dietary Manager) on 07/22/25 at 12:16 pm and Staff 1 (ED) on 07/22/25 at 12:30 pm. They acknowledged the findings.

1) All items identified during survey to be out of compliance due to cleanliness were deep cleaned on 7/31/25. Our cleaning checklist was updated to include the stated areas needing regular cleaning per observation. Education and training on updated cleaning checklist, uncleanable surface identification and proper food storage/handling practices to be provided to all staff on 8/12/25. The noted areas needing repaired will be completed to create cleanable surfaces. 2) The system will be corrected as evident by the implementation of a cleaning checklist. A cover has been purchased for the ice bucket and a scoop provided for the retrieval ice from the bucket. Scoops for the flour and baking soda removed from the bins and attached outside of bin. Education to the Dietary Manager will be provided to report repairs to maintenance. 3) The Dietary manager will perform routine cleaning inspections per Sapphire CQI/QA with Administrator oversight. 4) The Administrator is responsible to ensure that all the corrections are completed and monitored.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Refer to POC for C240

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 1 of 1 sampled resident (# 2) during ADL care and multiple unsampled residents during meal service. Findings include, but are not limited to: a. Resident 2 was admitted to the facility in 02/2025 with diagnoses including chronic inflammatory demyelinating polyneuritis and chronic pain syndrome. During interviews and observations from 04/28/25 through 04/29/25, Resident 2 was noted to require a two-person assist for incontinence care and for transfers with a mechanical lift. During an ADL observation on 04/29/25 at 12:50 pm the following was noted: * Two staff donned gloves, transferred the resident via mechanical lift to the bed and assisted the resident with incontinence care which included cueing, wiping and clothing adjustment; * Two staff rolled the resident side to side to provide assistance with removal of a soiled incontinence brief; * One staff provided perineal care, then proceeded to remove one glove, and applied barrier cream with the ungloved hand to the resident’s coccyx area. After having applied the barrier cream, the staff member donned the same glove. Staff then touched a clean incontinence brief, socks, pants, sling for mechanical lift and the lift itself and repositioned the resident using the soiled gloves; and * The staff members removed the soiled gloves and were not observed to have performed hand hygiene before resuming duties. b. Lunch service on the RCF and MCC were observed on 04/29/25 and 04/30/25. * Universal care staff were observed serving meals, pouring beverages and touching residents without performing hand washing and did not wear a protective barrier over potentially contaminated clothing. Maintaining effective infection prevention and control while providing ADL care and meal service was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Administrator-SNC), and Staff 6 (Specific Needs Director of Health Services) on 05/01/25. They acknowledged the findings.

A) 1) Proper peri-care procedure inservice given to all current care staff immediately on 4/30/2025. 2) As part of the onboarding process and competency checklist, designated clinical managers to ensure return demonstration on perineal care procedures prior to care staff being independent of a trainer. 3) Director of Health Services to ensure all current staff understand and show demonstration of proper perineal care procedures. Executive Director to monitor and evaluate that all current staff have been trained on perineal care and that all new staff have documented evidence that they had a designated clinical manger sign off that they were competent in proper perineal care procedures and standards. 3) Executive Director to monitor and evaluate this correction over the next 30 days per Sapphire CQI policy and monthly thereafter as part of our quality assurance program. B) 1) All staff were immediately in-serviced on proper apron use for serving meals in the dining room on 4/30/2025. Aprons for staff were purchased on 4/28/2025. System is in place on storage and usage of aprons. All staff were using appropriately in dining areas by 5/1/2025. 2) New staff will be educated in apron use ongoing as part of the onboarding process. 3) Admin and dietary manager will be responsible for oversight. 4) System will be monitored for the next 30 days per Sapphire CQI policy and monthly thereafter as part of our quality assurance program.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 2 of 2 sampled residents (#s 2 and 4) dependent on staff for ADL care. This is a repeat citation. Findings include, but are not limited to: 1. Resident 4 moved into the MCC in 09/2023 with diagnoses including vascular dementia and heart failure. Observations of the resident and interviews with staff on 07/10/25 revealed Resident 4 relied on staff for incontinence care. On 07/10/25 at 11:43 am, Staff 14 (CG) and Staff 16 (CG) donned gloves to provide ADL care for Resident 4. They used a sit-to-stand lift to transfer Resident 4 from his/her wheelchair to the toilet. Staff 16 pulled down Resident 4’s pants and incontinence brief before s/he was lowered to the toilet. After toileting, Staff 16 cleaned Resident 4’s perineal area. Without changing gloves or performing hand hygiene, Staff 16 used the mechanical lift to assist the resident to stand and pulled up his/her incontinence brief and pants. Staff 16 then removed the soiled gloves and washed his/her hands in the sink before assisting Staff 14 with returning Resident 4 to his/her wheelchair. Both CGs performed hand hygiene before they left the room. The need to ensure infection prevention and control protocols were maintained to provide a safe, sanitary, and comfortable environment was reviewed on 07/10/25 at 1:10 pm with Staff 1 (ED) and Staff 27 (Operations Support for Special Needs Contract). They acknowledged the findings. 2. Resident 2 moved into the facility in 2023 with diagnoses including chronic inflammatory demyelinating polyneuritis. Observations and interviews with staff during the survey identified Resident 2 relied on two staff for transfers and incontinence care needs. With permission from the resident on 07/10/25 at 11:46 am, Staff 25 (CG) and Staff 26 (CG) were observed providing ADL assistance with transfers and incontinence care. Staff 25 and Staff 26 transferred the resident from wheelchair to bed via mechanical lift. The CGs repositioned the resident in bed using the mechanical lift sling, adjusted the resident’s clothing and soiled brief, and cleaned the resident’s perineal area using disposable wipes. Staff 26 removed the soiled wipes and brief and placed them into a trash bag. Staff 25 and Staff 26 then repositioned the resident, placed the clean brief, adjusted the resident’s clothing, and transferred the resident from the bed to wheelchair. The staff touched the resident’s bare skin, clothing, bedding, mechanical lift sling, mechanical lift, and wheelchair without performing hand hygiene or changing gloves between tasks. Both staff doffed gloves and performed hand hygiene after assisting Resident 2 with the transfer into his/her wheelchair. The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 1 (Administrator) and Staff 27 (Operations Support for Specific Needs Contract) on 07/10/25 at 1:50 pm. They acknowledged the findings.

1. The community will retrain all staff members on infection prevention and control protocols. Peri-care training requiring a return demonstration will be provided to direct care staff. Return demonstration on handwashing to be completed by direct care staff. 2. Designated managers will conduct random peri-care audit observations to ensure that staff are following the correct procedures when providing peri-care to residents. 3. Infection control practices will be reviewed twice weekly with return demonstration to ensure proper peri-care glove use and hand hygiene practices. 4. The Executive Director, SNC Program Administrator, and Director of Health Services will monitor and evaluate the progress of this plan of correction.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 13 and 21) completed Department-approved pre-service dementia training courses before providing care to residents. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (Administrator) on 04/30/25. There was no documented evidence Staff 13 (MT), hired 02/20/25, and Staff 21 (CG), hired 02/19/25, completed Department-approved training in the following dementia care topics before providing direct care to residents: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need to ensure all Department-approved pre-service orientation dementia training courses were completed by newly hired staff before they provided direct care to residents was reviewed with Staff 1 (Administrator) on 04/30/25 at 12:32 pm. She acknowledged the findings.

1) Staff 13 and Staff 21 completed their required trainings immediately. 2) All Department-approved pre-service dementia training course completion certificates are to be collected and audited by Administrator with each newly hired staff. 3) Administrator and business office manager will be responsible for oversight. 4) System to be monitored for 30 days and with each new hire thereafter. This system will be monitored monthly as part of our quality assurance program.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records from 10/2024 through 04/2025 were reviewed and lacked the following: * Location of simulated fire drill; * Escape route used; and * Problems encountered relating to residents who resisted or failed to participate in the drills. The need to record all required components of the fire drill in accordance with the OFC was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director) on 04/30/25 at 12:28 pm. They acknowledged the findings

1) Fire drill training completed with Maintenance Director on 5/1/2025 describing the required components needing to be documented. 2) Sapphire Fire Drill form inclusive of all required components and administrator to ensure that all areas are completed after each fire dril to ensure completion. 3) Administrator and maintenance director to be responsible for oversight. 4) System to be monitored monthly as part of our quality assurance program.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

Based on observation and interview, it was determined the facility failed to ensure exterior pathways were made of smooth material, maintained in good repair, garbage was stored in covered refuse containers and measures were taken to prevent the entry of rodents. Findings include, but are not limited to: On 04/28/25 the facility was toured, and the following was identified: a. Throughout the survey period, multiple rats were observed scurrying across the RCF courtyard. Multiple piles of peanuts and corn cobs were observed near the planter boxes and in the courtyard. b. Multiple areas of raised seams and gaps in concrete were visualized in the RCF courtyard, posing a fall hazard to residents. c. The garbage container in the RCF courtyard did not have a lid, exposing bags of trash and food items. On 04/30/25 at 12:00 pm, the need to take measures to maintain smooth exterior pathways in good repair, take measures to prevent the entry of rodents, and store garbage in covered refuse containers was reviewed with Staff 1 (Administrator) and Staff 4 (Maintenance Director) during a tour of the environment. They acknowledged the findings.

1) Administrator met with a landscaper on 5/2/2025 to discuss a plan to get all uneven pathways in the exterior smoothed out. A new outdoor garbage receptacle bought on 5/14/2025 that has a cover to replace the current garbage container that does not have a lid. Signs that explicitly say not to feed the animals purchased on 5/14/2025 and to be posted throughout the outdoor courtyard area once received by the maintenance director. 2) Maintenance director to work with pest control vendor on a monthly basis to brainstorm ways to reduce the rat population. Maintenance director and administrator to ensure all garbage receptacles have lids, uneven pathways identified, and pest control measures in place monthly through community walk through audit. 3) Maintenance director and administrator to be responsible for monitoring the progress on these items. 4) System will be monitored once weekly for the next 30 days per Sapphire CQI policy and monthly thereafter as part of quality assurance program.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans.

Based on observation and record review, it was determined the facility failed to ensure hot water temperatures in residents’ rooms and common areas were maintained within a range of 110-120 degrees Fahrenheit (F). Findings include, but are not limited to: The facility was toured on 04/28/25 and the following was identified: a. Hot water in four of six sampled sinks measured between 122.7 and 139 degrees F. The sink measuring 139 degrees F was in Room 1 of a MCC resident’s bathroom. Staff 1 (Administrator) was alerted to the issue and confirmed the Maintenance Director was instructed to turn down the water heater. On 04/29/25 at 2:50 pm, the hot water faucet in Room 1 of the MCC measured 140.4 degrees. At 3:00 pm, Staff 1 stated the hot water had been turned off in the wing of the facility where hot water temperatures were recorded as being above the required range. On 04/30/25 at 8:55 am the hot water in Room 1 of the MCC was measured at 142.3 degrees F. Staff 1 was alerted to the findings. At 9:20 am it was observed the hot water in Room 1 had been turned off. Staff 1 confirmed a plumber will be installing mixer valves to correct the issue on 05/02/25 and the hot water would remain off until that time. b. Water temperature logs dating 01/04/25 to 03/15/25 were reviewed. Hot water temperatures exceeded common areas throughout the review period. The need to ensure hot water temperatures in residents’ units and common areas did not exceed 120 degrees F was discussed with Staff 1 and Staff 4 (Maintenance Director) at 04/30/25 at 12:00pm. They acknowledge the findings.

1) All water heaters that service resident rooms and shower rooms have been replaced as of 5/7/2025. These water heaters have been calibrated to ensure that the water temperatures do not exceed 120 degrees F. 2) Maintenance director to conduct weekly hot water temperatures and review with administrator to ensure the water temperatures are under the expected 120 degrees F. 3) Maintenance director and administrator to be responsible for oversight. 4) Water temperature system to be monitored once weekly for the next 30 days per Sapphire CQI policy, and monthly thereafter as part of QA program.

OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C420 and C545.

Refer to C420 and C545.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 295.

Refer to C295

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 12, 20 and 23) completed required pre-service dementia training before providing care to residents. Findings include, but are not limited to: a. There was no documented evidence Staff 20 (CG), hired 01/09/25, completed the following pre-service dementia training prior to providing direct care to residents in the MCC: * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and * Use of supportive devices with restraining qualities in memory care communities. b. There was no documented evidence Staff 12 (CG), hired 12/03/25, and Staff 23 (MT), hired 01/03/25, completed the following Department-approved training before providing direct care to residents in the MCC: * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach; * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and * Use of supportive devices with restraining qualities in memory care communities. The need to ensure all required pre-service orientation dementia training courses are completed by newly hired staff before they provided direct care to residents was reviewed with Staff 1 (Administrator) on 04/30/25 at 12:32 pm. She acknowledged the findings.

Refer to C370.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

Based on observation and interview, 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 295.

Refer to C295

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

Based on observation, interview and record review, conducted during a site visit on 04/24/25, the facility's failure to ensure the implementation of services was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to: At 12:48 pm, Resident 5 was observed in his/her shared restroom with an activated call light. At 12:55 pm, Staff 9 (Caregiver) was observed to enter Resident 5's room and exit within one minute. At 1:02 pm, Staff 9 returned to Resident 5's room. At 1:20 pm, Resident 5 was observed laying in his/her bed and fall mat was tucked completely under resident's bed. In an interview on 04/24/25, Resident 5 stated s/he needed help and that s/he needed to use the toilet. In an interview on 04/24/25, Staff 9 stated Resident 5 needed toileting assistance, but there were not enough staff to transfer the resident to the toilet and s/he was advised to use the brief s/he was wearing. S/he stated s/he transferred Resident 5 into bed and then changed his/her briefs. A review of Resident 5's service plan, dated 02/24/25, indicated Resident 5 had mixed continence of bladder and bowel with a goal to be able to maintain bladder and bowel function with assistance. Under the section of transferring indicated Resident 5 required the assistance of two staff members for all transfers via sit to stand. Service plan had no information regarding Resident 5's fall mat. There was no evidence a temporary service plan was implemented for Resident 5's fall mat. The facility failed to ensure the implementation of services according to the resident's service plan. On 04/24/25, those findings were reviewed and acknowledged by Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (Director of Health Services).

Based on interview and record review, conducted during a site visit on 04/24/25, the facility's failure to update and maintain an Acuity Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to: A review of Resident 5's service plan dated 02/24/25 did not accurately reflect Resident 5's care needs and was not reflected in the ABST evaluation. The facility's posted staffing plan and ABST were reviewed and compared with the facility's staff schedule from 04/18/25 - 04/24/25. A total of 126 shifts reviewed indicated the facility was not staffed to the posted staffing plan by one care staff for 19 of 126 shifts. In an interview on 04/24/25, Staff 10 (RCC) stated s/he created the schedules for all of the departments and based the schedule on the ABST times, not the posted staffing plan. In an interview on 04/24/25, Staff 1 (Executive Director) stated the management team captured unscheduled needs by reviewing call light usage then interviewed staff about reasons residents used call lights to increase time on the ABST. A review of the ABST Answer Export dated 04/24/25 indicated six residents had not been updated in the last quarter as required. The facility failed to update the residents' ABST evaluations no less than quarterly, failed to accurately capture care time and care elements that staff are providing to each resident; and failed to provide direct care staff sufficient in numbers to meet the unscheduled needs of each resident. On 04/24/25, those findings were reviewed and acknowledged by Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (Director of Health Services).

Based on interview and record review, conducted during a site visit on 04/24/25, the facility's failure to update and maintain an Acuity Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to: A review of Resident 5's service plan dated 02/24/25 did not accurately reflect Resident 5's care needs and was not reflected in the ABST evaluation. The facility's posted staffing plan and ABST were reviewed and compared with the facility's staff schedule from 04/18/25 - 04/24/25. A total of 126 shifts reviewed indicated the facility was not staffed to the posted staffing plan by one care staff for 19 of 126 shifts. In an interview on 04/24/25, Staff 10 (RCC) stated s/he created the schedules for all of the departments and based the schedule on the ABST times, not the posted staffing plan. In an interview on 04/24/25, Staff 1 (Executive Director) stated the management team captured unscheduled needs by reviewing call light usage then interviewed staff about reasons residents used call lights to increase time on the ABST. A review of the ABST Answer Export dated 04/24/25 indicated six residents had not been updated in the last quarter as required. The facility failed to update the residents' ABST evaluations no less than quarterly, failed to accurately capture care time and care elements that staff are providing to each resident; and failed to provide direct care staff sufficient in numbers to meet the unscheduled needs of each resident. On 04/24/25, those findings were reviewed and acknowledged by Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (Director of Health Services).

Based on interview and record review, conducted during a site visit on 04/24/25, the facility's failure to update and maintain an Acuity Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to: A review of Resident 5's service plan dated 02/24/25 did not accurately reflect Resident 5's care needs and was not reflected in the ABST evaluation. The facility's posted staffing plan and ABST were reviewed and compared with the facility's staff schedule from 04/18/25 - 04/24/25. A total of 126 shifts reviewed indicated the facility was not staffed to the posted staffing plan by one care staff for 19 of 126 shifts. In an interview on 04/24/25, Staff 10 (RCC) stated s/he created the schedules for all of the departments and based the schedule on the ABST times, not the posted staffing plan. In an interview on 04/24/25, Staff 1 (Executive Director) stated the management team captured unscheduled needs by reviewing call light usage then interviewed staff about reasons residents used call lights to increase time on the ABST. A review of the ABST Answer Export dated 04/24/25 indicated six residents had not been updated in the last quarter as required. The facility failed to update the residents' ABST evaluations no less than quarterly, failed to accurately capture care time and care elements that staff are providing to each resident; and failed to provide direct care staff sufficient in numbers to meet the unscheduled needs of each resident. On 04/24/25, those findings were reviewed and acknowledged by Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (Director of Health Services).

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 04/24/24 at 11:10 am, the following concerns were observed: * Kitchen staff carried a sheet pan of individual servings of dessert that were uncovered, using the elevator to the second floor; * Dishwashing area: the wall underneath spray hose sink and the wall behind the dishwasher had significant drips/splatters of black/brown matter; * The ceiling vent above dishwasher had an accumulation of dust build-up; * The hood vents above stove/grill had an accumulation of grease and dust; and * Improper glove use, including not washing hands between glove changes and not changing gloves (or washing hands) upon returning to the kitchen. The areas of concern were observed and discussed with Staff 1 (Dietary Manager) and discussed with Staff 2 (Executive Director) on 04/24/24. The findings were acknowledged.

1. All kitchen staff have been trained on the proper procedures to take food to the second floor dining room and resident rooms including ensuring that all open food containers are cocvered before leaving the kitchen. This be monitored daily by the dietary manager and other cooks on the schedule 2. We have implemented a cleaning schedule for the dishwashing area. This includes night cleaning of the area under the dishwasher/sink as well as the wall behind the dishwasher. This will be monitored by the dietary manager as well as the cook in charge on a regular basis 3. The ceiling vent above the dishwaher has been added to the weekly cleaning schedule/checklist. This will be monitored by the dietarty manager for compliance. 4. The hood vents above he stove/oven area have also been added to the weekly/as needed cleaning checklist. Kitchen staff have been training on proper cleaning of these vents. The dietary manager will monitor this for compliance 5. Proper gloves usage training has been provided to all Kitchen staff and will be part of any new hire training to ensure that handwashing is completed between glove use as well as when re-entering the kitchen.  This training will be done by the dietary manager who will monitor  ongoing compliance.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Refer to C 240

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

The findings of the revisit to the kitchen inspection of 04/24/24, conducted on 07/02/24, are documented in this report. The facility was found in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 06/01/23 at 11:35 am the following concerns were observed during the facility kitchen observation: * Two trays of individual servings of pudding stored on roll in cart were uncovered in the walk in refrigerator; * Three garbage cans were stored without lids, at the time they were not actively being used; * The interior of the microwave had food splatters; and * All ceiling lights throughout the kitchen did not have covers protecting the light bulbs. The areas of concern were observed and discussed with Staff 1 (Dietary Services Manager and Staff 2 (Executive Director) on 06/01/23. The findings were acknowledged.

Uncovered Items: The two uncovered pudding trays to be used for lunch were removed from walk-in. The Dietary manager and ED have reveiwed the policy and practice of properly covering product when in refridgerator. Kitchen staff have been in-serviced on properly covering product on 6/16/23. The Dietary manager will perform routine product checks per Sapphire QA protocol to ensure that stowed items are properly covered ongoing. The dietary manager will be responsible for ongoing training of kitchen staff and monitoring for compliance. Garbage Cans uncovered: New garbage cans with lids were purchased and arrived on 6/15/23 with lids are the swinging type so that the garbage cans will be covered. Kitchen staff were inserviced on importance of lid use on 6/21/23. The Dietary Manager will perform routine checks per Sapphire QA protocol to ensure lids are on cans. Interior of the microwave had food splatters: Microwave was cleaned of splatter immediately on 6/1/23. Microwave cleaning was added to kitchen cleaning list. Staff were in-serviced 6/21/23 to check the microwave cleanliness after each use to ensure that it remains clean.   The dietary manager will be responsible to perform routine checks per Sapphire QA protocol to ensure compliance. Ceiling Lights are uncovered: Picture and light brand was collected on 6/20/23 and sent to supplier to assist in sourcing light covers. Efforts will be made to source light covers and will be installed once procured.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to  C240.

See C240.

The findings of the kitchen inspection, conducted 06/01/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 06/01/23, conducted 08/16/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include the following: During an unannounced site visit on 08/11/2022 Compliance Specialist (CS) reviewed the facilities staff schedules for the months of June- August 2022. CS reviewed staff schedules against facilities posted staffing plan. Facility had multiple open shifts that don't appear to have been filled as well as multiple days where the facility was not staffing according to their posted plan. In an interview with an unsampled resident it was stated that it was their shower day and they had not yet received their shower. CS reviewed residents shower schedule and confirmed that they were scheduled for Thursday morning showers. In separate interviews with Staff #3 and Staff #7 (S3 & S7) the following was stated: · I don't believe (unsampled resident) has received their shower yet, I doubt they have · I don't know if they have had their shower, day shift didn't tell me if they needed a shower still. Findings were shared with Staff #1 and Staff #8 (S1 & S8) who acknowledged findings.

Based on interview and record review it was confirmed that the facility failed to have an Acuity Based Staffing Tool that accurately reflected the resident population and their needs. Findings include the following: During an unannounced site visit on 08/11/2022 Compliance Specialist (CS) reviewed the facilities Acuity Based Staffing Tool (ABST) against the facilities current resident roster and found 1 resident in the acuity tool that was no longer on the resident roster and 2 residents on the resident roster that had moved-in in July 2022 that were not listed in the ABST. CS reviewed the most current service plans for Resident #3 and Resident #4 (R3 & R4) against the facility ABST for both residents inconsistencies were identified between each residents service plans and their ABST questions. In separate interviews with R3 and R4 the following was stated: · I need assistance with dressing and some incontinence assistance · I need help getting my shoes on Neither Residents ABST ' s were reflective of their voiced needs In an interview with Staff #1 (S1) it was stated that they had not updated their ABST since getting the information put in, but they will work on getting it current and check into the noted inconsistencies.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 8/11/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

2. Resident 5 was admitted to the memory care unit in April 2021 with diagnoses including dementia. Progress notes indicated Resident 5 had an unwitnessed fall on 10/27/21 at 5:57 am, bruising found on 11/10/21 at 2:58 am and a second unwitnessed fall on 11/10/21 at 9:25 pm. An incident report, dated 10/27/21, stated the resident was found on the floor while the night shift staff were doing their last rounds. The report included Resident 5's statement that s/he fell on his/her bottom. There was no additional information to show how the facility was able to rule out abuse or neglect. A progress note, dated 11/10/21, stated the resident was on alert charting for the above mentioned fall on 10/27/21 and went on to report, "Resident has bruise on knee (R) which is dark purple." There was no follow up documentation indicating where the bruising came from and if it was related to the fall. An incident report, dated 11/10/21, reflected, "Resident stated [s/he] was trying to stand up and use [his/her] phone but fell backwards onto [his/her] buttocks. [S/He] denied any pain from the fall. No visible injuries noted." There was no additional information to show how the facility was able to rule out abuse or neglect for the unwitnessed fall. The need to ensure all incidents were investigated and reported to the local SPD office as appropriate was discussed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure unwitnessed falls and resident incidents were thoroughly investigated to rule out abuse/neglect and reported to the local SPD office, as appropriate, for 2 of 3 sampled residents (#s 1 and 5) with incidents. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in June 2021 with diagnoses including dementia. Progress notes indicated Resident 1 had an unwitnessed fall on 01/01/22. An incident report, dated 01/01/22, stated Resident 1 was found on the floor and "another resident was laying in resident's bed where [s/he] was previously laying before being found on the floor." The initial incident documentation revealed staff were unable to determine what happened and unable to rule out abuse or neglect. There was no documented evidence the facility immediately reported the incident to the local SPD office and investigated to determine ways to prevent the reoccurrence. The need to ensure all incidents were investigated and reported to the local SPD office as appropriate was discussed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings and the above incident was reported to the local SPD office on 01/06/22, per surveyors request.

1 - Resident #1 Incident was reported to local APS office during time of survey and closed at intake. Resident #5 all incident reports reviewed and not negative outcomes to sited residents. 2 - All incident reports will be reviewed daily during stand-up/clincial team meetings to assure that all incidents are being investigated and reported timely. ED and RN/DHS will assure that incident reports are signed and meet requirements. 3 - All current staff will be in-serviced on abuse/neglect reporting and investigations. All new staff will be inserviced on Abuse/Neglect reporting as part of their onboarding process. 4 - ED, RCCs, RN/DHS will QA two incident reports/month as part of the ongoing QA process Executive Director, Director of Health Services

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 01/04/22 at 11:30 am, the facility kitchen was observed to need cleaning and repair in the following areas: a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following: * Walls throughout the kitchen; * Underneath the dish machine and three compartment sink; and * Floor perimeter. b. The following areas needed repair and/or cleaning: * The walk-in freezer had a large accumulation of ice throughout, including on the fans; * The area around the ceiling vents had missing paint, were peeling and/or had holes; * The faucet of the three compartment sink was running and could not be turned off; and * The fire sprinkler above the plate warmer was covered with dirt and cobwebs. The areas that required cleaning and repair were observed and discussed with Staff 1 (Regional Director) on 01/06/22. The findings were acknowledged.

1 - Kitchen deep cleaning will take place including walls, floors, and all surfaces mentioned in 2567. Kitchen repairs as indicated are in process and will be fixed by compliance date. 2 - Dietary manager and staff will use work order, kitchen cleaning audits and weekly walk throughs for on-going complaince. 3- Weekly as a part of ongoing compliance ED, RDO, Dietary Manager, Maintenance Director Responsible

2. Resident 6 was identified as a smoker during the acuity interview on 01/04/22. Interviews with Resident 6, Staff 1 (Regional Director) and Staff 3 (RCC) on 01/04/22 and 01/06/22 confirmed Resident 6 smoked independently. Although smoking was documented on the service plan, there was no documented evidence a smoking safety evaluation had been completed since 03/03/20. The facility's failure to complete a quarterly smoking evaluation was discussed with Staff 1 on 01/06/22. She acknowledged the findings. 3. Resident 2 was admitted to the memory care unit December in 2021 with diagnoses including dementia. The following components were not addressed on the resident's move-in evaluation: * Interests, hobbies, social and leisure activities; * Confusion and decision making abilities; * Personality including how the person copes with change or challenging situations; * Assistance needed for personal hygiene; * Assistive devices relating to mobility; and * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature. The need to ensure all required components were addressed on the move-in evaluation was discussed with Staff 1 (Regional Director) and Staff 2 (RN) on 01/06/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure quarterly smoking evaluations were completed timely for 2 of 2 sampled residents (#s 6 and 7) and ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2)  whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 7 was identified as a smoker during the acuity interview on 01/04/22. Interviews with Resident 7 on 01/04/22 confirmed s/he smoked multiple times a day, independently. Although smoking was documented on the service plan, there was no documented evidence a smoking safety evaluation had been completed since 05/14/21. The facility's failure to complete a quarterly smoking evaluation was discussed with Staff 1 (Regional Director) and Staff 3 (RCC) on 01/06/22. They acknowledged the findings.

1 - Resident #6 and #7 Smoking evaluations have been completed. A complete audit of all community smokers will be conducted to assure that evaluations are completed. Resident #2 was re-assesed with updated evaluation tool completed. 2 - RNC educated interdisciplanary team on move-in evaluations and evaluation process. All evaluations will be done in conjunction with the residents service plan ongoing 3 - ED will review all move-in evaluations for completeteness to assure all components as required. An audit of evaluations will be conducted as part of the monthly QA process for ongoing compliance ED is reponsible

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs and provided clear direction to staff regarding the delivery of services for 4 of 6 sampled residents (#s 1, 2, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in October 2015 with diagnoses including MS and was able to self-direct his/her own care. Resident 6's service plan included "Has a port, that is taken care of by Providence Home Infusion." There was no further information on the care and safety of the port or what concerns staff should watch for and report. In interview on 01/06/22, Staff 1 (Regional Director) confirmed Resident 6 had a port in his/her upper right chest that was managed by an outside provider. The need to ensure the service plan was reflective of the resident's status and care needs was discussed with Staff 1 on 01/06/22. She acknowledged the findings. 3. Resident 2 was admitted to the memory care unit in December 2021 with diagnoses including dementia. Observations from 01/04/22 through 01/06/22 were made, interviews with staff were conducted and medical records were reviewed. The following components were either not reflective of the resident's current care needs or did not provide clear direction to caregiving staff: * Daily routine; * Bathing; * Grooming and personal hygiene assistance; * Oral hygiene including brushing natural teeth and caring for partial dentures; * When to provide housekeeping and laundry services; * Making choices within his/her own abilities and what those are; * Behaviors, how the resident exhibits them and interventions; * How often to check on the resident; * Assistance needed with toileting; * Transfer pole; * Dining preferences and assistance needed; * Mobility; * Preference for the resident's door to be locked; and * Preference to stay in bed. 4. Resident 5 was admitted to the memory care unit in April 2021 with diagnoses including dementia. Observations from 01/04/22 through 01/06/22 were made, interviews with staff and the resident's family were conducted and medical records were reviewed. The following components were either not reflective of the resident's current care needs or did not provide clear direction to caregiving staff: * Behaviors, including how the resident exhibits them and interventions; * Frequency of safety checks; * Time the resident spends in his/her room; * Sleeping routine and preferences; * Dressing assistance; * Toe guard placement; * Grooming assistance including hand and face washing and oral care; * Chair alarm; * Bed alarm; * Siderails relating to use, what to monitor them for and who to report to if they are loose or in need of repair; * Mobility device used; * Ambulation assistance; * Ability to transfer out of bed independently with the perimeter mattress; * Sleep interventions including exercise and napping; * Daily routine; * Fall interventions; * Where the resident eats meals; * Left hand splint; * Frequency of checks relating to toileting assistance; and * Interventions relating to nose bleeds. The need to ensure residents' service plans were reflective of their current provision of care and provided clear caregiving instruction was discussed with Staff 1 (Regional Director) and Staff 2 (RN) on 01/06/22. They acknowledged the findings. 2. Resident 1 was admitted to the facility in June 2021 with diagnoses including dementia. The current service plan, dated 09/15/21, and temporary service plans were reviewed. The service plan was not reflective of the resident's current status in the areas of: * Use of devices including a bed alarm, wheelchair and protective head gear; * Current activities and ability to participate; * Mobility; * Fall risk and current interventions; and * Locking of the apartment door. During interviews on 01/04/22 and 01/06/22, direct care staff stated the resident needed a wheelchair for most mobility, used head protective gear and a bed alarm daily, and the door to the apartment was kept locked. The need to ensure service plans were reflective of residents' current status was discussed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

1 - Resident 1, 2, 5, 6 service plans will be updated and care conference held 2 - ED to conduct inservice with staff on the proper service planning process and to review OAR with the service planning team to assure that all areas of resident care and needs are met as part of the service planning process. Evaluation tool in PCC was changed to feed directly to the service plan 3 - As part of the monthly internal QA process community will audit 2 SPs for accuracy RN, RCCs, ED are responsible

2. Resident 2 was admitted to the memory care unit in December 2021 with diagnoses including dementia. The resident's clinical records were reviewed and staff were interviewed. A facility document entitled SL Resident Evaluation, dated 11/18/21, reflected the resident became "anxious when the spouse was not available, even just to go into the other room." It also reflected Resident 2's spouse lived in Seaside, Oregon which was a two hour trip to the facility. In an interview on 01/05/22 at 10:05 am, Staff 10 (MC CG) confirmed the resident preferred to stay in his/her bed, screamed when taken out of his/her room and was not doing well with the transition. The resident had been evaluated by home health speech therapy on 12/21/21 and put on a pureed diet. Staff 10 reported Resident 2 only took one to two bites of meals and drank about one third of the nutritional supplement that was offered three times a day. There was no documented evidence Resident 2 was monitored upon admission for signs or symptoms of anxiety or loss due to being away from his/her spouse. There was also no documented evidence staff communicated to management the resident's decreased intake after the speech evaluation was completed and the pureed diet was implemented. 3. Resident 5 was admitted to the memory care unit in April 2021 with a diagnosis of dementia. Progress notes, dated 09/20/21 through 01/03/22 were reviewed and revealed the following incidents had not been monitored through resolution: *  09/20/21 - Increased confusion during the night; * 11/02/21 - Covid booster administered; * 11/08/21 - Urinary tract infection; * 11/09/21 - Start of a new medication; * 11/10/21 - Bruising to right knee; * 11/10/21 - Non-injury fall; and * 12/23/21 - Left index finger abnormality. Resident 5 had a fall on 10/27/21 and on 11/10/21. Neither fall had documented evidence of new interventions implemented and monitored for effectiveness. The need to determine and document what actions or interventions were needed when a resident experienced changes of condition, monitor the interventions for effectiveness and monitor changes of condition through resolution was discussed with Staff 1 (Regional Director) and Staff 2 (RN) on 01/06/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to identify changes of condition, determine and document what actions or interventions were needed for the resident, communicate these to staff and monitor the conditions to resolution for 3 of 6 sampled residents (#s 1, 2 and 5) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in June 2021 with diagnoses including dementia. a. Review of Resident 1's clinical record revealed the resident experienced multiple falls between 10/08/21 and 01/01/22. Several of the falls resulted in injuries to the resident. Incident reports and investigations were reviewed and lacked any new interventions identified to try and prevent additional falls. The facility had some interventions in place, however, there was no documented evidence the interventions were being monitored for effectiveness. Direct care staff interviewed on 01/05/22 stated Resident 1 remained unsteady on his/her feet, required use of a wheelchair for mobility and a bed alarm that was used to alert staff when the resident moved in bed. b. Resident 1's clinical record revealed the resident had multiple skin injuries which occurred between 10/2021 and 01/2022, including the following: * 10/08/21: laceration with sutures to forehead; * 11/24/21: toenail removed; * 11/30/21: laceration to head; and * 11/30/21: skin tear to elbow. The record lacked documentation weekly of progress noted until the conditions resolved. On 01/06/22 the need to determine and document what actions or interventions were needed when a resident experienced changes of condition, monitor the interventions for effectiveness and monitor skin conditions to resolution was discussed with Staff 1 (Regional Director). She acknowledged the findings.

1 - Residents 1,2,5 Change of Condition were reviewed and documentation completed reflecting the changes and SP updated as needed. 2 - 24 hour process will be reviewed and retrained with staff to assure that communication from staff regarding visualized changes are being documented for further follow up. RN, ED, RCCs, will review in clincical meeting daily and address/document accordingly. Training to be conducted with facility care staff 3 - Review of 24 hour binder and audit tool will be conducted Mon-Fri during clinical meetings ED, RN, RCCs are responsible

Based on interview and record review, it was determined the facility failed to ensure physician orders were documented in the resident's facility record or were carried out as prescribed for 2 of 7 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in December 2021 with diagnoses including dementia. Current physician's orders and the 12/13/21 through 01/04/22 MARs were reviewed. There was no documented evidence of a physician's order in the resident's facility record for scheduled acetaminophen (used to treat pain) and no clear orders relating to administering either 50 mgs or 100 mgs of Losartan (used to treat high blood pressure). The need to ensure there were physician orders located in the resident's facility record for all medications the facility was responsible to administer and the facility was following physician orders for those medications was discussed with Staff 1 (Regional Director) and Staff 2 (RN) on 01/06/22. They acknowledged the findings. 2. Resident 1 moved into the facility in June 2021 with diagnoses including dementia. Signed physician orders on 10/05/21, and the 11/01/21 through 01/04/22 MARs were reviewed and revealed the following orders were not followed: * Polyethylene Glycol (bowel medication): take 17 g by mouth daily, can use as needed for constipation; and * Sennosides-Docusate Sodium 50 mg oral tab (bowel medication): take 1 tablet by mouth 2 times a day as needed for constipation. In a discussion with Staff 1 (Regional Director), she indicated hospice would be contacted and the orders would be clarified and followed. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 on 01/06/22. She acknowledged the findings .

1 - Comprehensive physican's order review was  conducted for residents #1, and #2, in addition all physican orders will be reviewed for accuracy by date of compliance 2 - Inservice all facility Med Techs on order processing and review 3 - Audit Physician's orders alongside the MAR weekly for 6 weeks and the monthly after during 24 hour review process. Bring any findings to internal QA meeting monthly RCC's/RN/ED responsible

Based on interview and record review, it was determined the facility failed to notify the physician or prescriber when a resident refused to consent to orders for 2 of 2 sampled residents (#s 2 and 5) who had documented medication and treatment refusals. Findings include, but are not limited to: Resident 2's 12/13/21 through 01/04/22 and Resident 5's 12/01/21 through 01/04/22 MARs and corresponding progress notes were reviewed. The residents' record showed multiple medication and treatment refusals. There was no documented evidence the facility notified the physician each time the residents refused to consent to the orders. The need to ensure the facility notified physicians of medication and treatment refusals was discussed with Staff 1 (Regional Director) and Staff 2 (RN). They acknowledged the findings.

1 - Resident #2 and #5 orders to be updated to reflect MD preference for notifcation when medication is refused. 2 - Inservice Med Techs and RCCs on proper notification of refused medications. 3 - RCC's to check for refused medications daily and assure proper notifications were made x4 weeks and then spot check 2 monthly as part of internal QA process. Bring findings to monthly internal QA meetings RCC's/RN/ED responsible

5. Resident 2 was admitted to the memory care unit in December 2021 with diagnoses including dementia. The resident's 12/13/21 through 01/04/22 MARs and progress notes were reviewed and revealed the following: * References to "hold/see nurse notes" on multiple entries with no documentation on why the medication was held or corresponding nurses notes; and * Multiple blanks without documentation of if the medication was administered. 6. Resident 5 was admitted to the memory care unit in April 2021 with diagnoses including dementia. The resident's 12/01/21 through 01/04/22 MARs and progress notes were reviewed and revealed multiple blanks on the MARs without documentation if the medication and treatments were administered. The need to ensure residents' MARs were accurate and included documentation of medications administered or why a medication was held was discussed with Staff 1 (Regional Director) and Staff 2 (RN) on 01/06/22. They acknowledged the findings. 3. Resident 3 was admitted in December 2015 with diagnoses including hyperlipidemia and chronic pain. The residents 12/2021 and 01/01/22 through 01/05/22 MARs and physician orders dated 09/23/21 were reviewed and revealed the following: * Staff failed to initial on the MAR if the resident's blood pressure and pulse were obtained on 12/04/21 and 01/04/22; and * PRN pain medications prescribed for the same condition lacked resident specific parameters and clear instruction for unlicensed staff regarding administration; On 01/06/22 the need to ensure MARs were accurate and PRN medications contained clear instructions to unlicensed staff was discussed with Staff 1 (Regional Director). She acknowledged the findings. 4. Resident 1 was admitted in June 2021 with diagnoses including dementia. The residents 11/01/2021 through 01/04/22 MARs and physician orders were reviewed and revealed the following: The January 2022 MAR had a physician's order for Bisacodyl 10 mg suppository, as needed for constipation. The PRN bowel medication lacked resident specific parameters and clear instruction for unlicensed staff regarding when to administer the medication. On 01/06/22 the need to ensure MARs were accurate and PRN medications included clear instruction for staff was discussed with Staff 1 (Regional Director). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs included reason for use, resident-specific parameters for PRN medications, staff signatures for administering medication, specific instruction to unlicensed staff on what time to administer medications or that reference notes had been followed up on for 6 of 7 sampled residents (#s 1, 2, 3, 4, 5 and 7) whose MARs were reviewed. Findings include, but are not limited to: 1.  Resident 4's 12/01/21 through 01/04/22 MARs were reviewed and revealed the following inaccuracy: The MAR instructions for the following medications - finasteride, clopidogrel bisulfate, protonix delayed release, trelegy ellipta aerosol powder and refresh lacri-lube ointment stated a range of times for administration of medications, but did not provide specific instruction to unlicensed staff on specific administration times. In an interview with Staff 2 (RN) on 01/05/22 at 2:20 pm, she stated she was unsure why there were a range of times and not a specific time. In an interview with Staff 3 (RCC) on 01/06/22 at 9:55 am, she stated the pharmacy sent the prescriptions with a range of administration times. The need to ensure unlicensed staff were given clear instruction on when to administer medication was discussed with Staff 1 (Regional Director) on 01/07/22. She acknowledged the findings. 2.  Resident 7's 12/01/21 through 01/04/22 MARs were reviewed and revealed the following inaccuracy: The MAR instructions for the following medications - dapsone, finasteride, tamsulosin HCI and titropium bromide monohydrate stated a range of times for administration of medications but did not provide specific instruction to unlicensed staff on specific administration times. In an interview with Staff 2 (RN) on 01/05/22 at 2:20 pm, she stated she was unsure why there was a range of times and not a specific time. In an interview with Staff 3 (RCC) on 01/06/22 at 9:55 am, she stated the pharmacy sent the prescriptions with a range of administration times. The need to ensure accuracy of MAR documentation and document a specific time to administer medications was discussed with Staff 1 (Regional Director) on 01/07/22. She acknowledged the findings.

1 - Residents 1, 2, 3, 4, 5, and 7 medication times were changed to be reflective of adminstration times and not range of times. 2 - PCC restrictions made to med pass times to not allow for ranges. Inservice provided to RCC regarding proper order confirmation 3 - Audit times for accuracy in PCC monthly as a part of QA process 4 - RCC's responsible

Based on interview and record review, it was determined the facility failed to ensure an accurate TAR with documentation of administration and specific treatment orders by a legally-recognized practitioner was provided for 1 of 3 sampled residents (#1) who received wound care treatments. Findings include, but are not limited to: Resident 1 was admitted to the facility in June 2021 with diagnoses including dementia. * Resident 1's progress notes, reviewed from 10/08/21 through 01/04/22, documented wound care was provided by facility staff to a head laceration and multiple skin tears; and * On 11/23/21, there was a physician order for soaking a toe twice daily and applying antibiotic cream and a bandage for 7 - 10 days. The 11/01/21 through 01/04/21 TARs were reviewed. The orders for wound care (skin tears, cuts, lacerations, etc.) had not been transcribed to the TAR, and there was no documentation by staff of any of the treatments provided. The lack of a documented treatment record for Resident 1's wound care was discussed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

1 - Resident #1 treatment area assessed and recap note made 2 - Inservice to be completed with DHS/RN, RCCs, Program Director, Med Techs assuring all treatment orders and wound care is transcribed into the TAR per MD orders 3 - ED, DHS/RN, RCCs to review all skins and treatment orders during 24 hour process and assure transcription accuracy Mon-Fri during 24 hour process RCC/DHS/ED responsible

Based on interview and record review, it was determined the facility failed to ensure a resident who self administered an inhaler was evaluated at least quarterly to ensure the ability to self administer medications for 1 of 1 sampled resident (#4). Findings include, but are not limited to: Resident 4 was admitted to the facility in October 2012 with diagnoses including chronic obstructive pulmonary disease. A physician order noted the resident was able to self administer an albuterol inhaler PRN every six hours. Staff 3 (RCC) verified the use of the inhaler. There was no evaluation of the resident's ability to safely administer the inhaler and keep it in his/her room. In an interview on 01/05/22 at 2:20 pm, Staff 2 (RN) indicated she was aware the resident had an order to self-administer her/his inhaler and had not yet completed an evaluation of the resident's ability to self administer medications. The need to complete evaluations of a resident's ability to self administer medications at least quarterly was discussed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

1 - Resident #4 self med eval was completed for PRN inhaler use. A complete audit of all resident medications including ability to self-administer and evaluations to be completed by compliance date. 2 - Inservice staff on the need for self-med evals for any resident who resides in RCF, who to notify, and proper physcian's order required.Review of evals to be done quarterly in conjunction with the service plan process 3 - Will review 2 resident evals per quarter as part of the internal QA process RCC/RN/ED  responsible

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired direct care staff (#s 10,11 and 12) completed all required pre-service orientation prior to beginning their job responsibilities. Findings include, but are not limited to: Facility training records were reviewed with Staff 16 (Regional Director of Operations) on 01/05/22. The following deficiencies were revealed: 1. Staff 10 (MC CG) hired 11/16/21 lacked documented evidence of the following pre-service orientation topics: * Standard precautions for infection control; and * Fire safety and emergency procedures. 2. Staff 11 (MC CG) hired 11/25/21 lacked documented evidence of a written job description. 3. Staff 12 (CG) hired 12/02/21, lacked documented evidence of the following pre-service orientation topics: * Abuse reporting requirements; * Fire safety and emergency procedures; and * Written job description. The need to ensure all required pre-service orientation was completed prior to newly hired direct care staff beginning their job responsibilities was reviewed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

1 - Audit all employee files for the presence of all required preservice orientation items including fire/life safety, universal precuations, written job description etc. 2 - New employee onboarding process to be reviewed with BOM and assure that new hire checklist is completed and accurate for all new employees 3 - Master training grid to be used to track all employee training hours, and competencies. Once all employee files have been audited, ED to audit 3 files/month for accuracy and completeness. Audit findings to be brought to internal QA meeting 4 - ED and BOM responsible

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired direct care staff (#s 10, 11 and 12) demonstrated satisfactory performance in all assigned areas within 30 days of hire. Findings include, but are not limited to: Training records were reviewed with Staff 16 (Regional Director of Operations) on 01/05/22 and revealed the following: 1. Training records for Staff 10 (MC CG) hired on 11/16/21 lacked documented evidence competency was demonstrated in the following areas: * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. 2. Training records for Staff 11 (MC CG) hired on 11/25/21 lacked documented evidence competency was demonstrated in the following areas: * General food safety, serving and sanitation; and * First Aide/Abdominal thrust. 3. Training records for Staff 12 (CG) hired on 12/02/21 lacked documented evidence competency was demonstrated in the following areas: * Role of the service plan in providing individualized care; * Providing assistance with ADL's; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation; and * First aide/abdominal thrust. The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was reviewed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

1) Audit all employee files for the presence of required pre-service dementia training in all topics required by OAR's   2) New Onboarding check list will be utilized to ensure employees complete the required onboarding process   3) Master Training Grid will be used to track and audit trainings. Once all current employee files are in compliance, an audit of 3 employee files will be conducted monthly for ongoing compliance   4) BOM and ED responsible

Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills were conducted every other month and included all required components and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Facility fire drill records dated 07/2021 through 10/2021, were reviewed on 01/05/2022. The facility lacked documented evidence unannounced fire drills were conducted every other month and included the following components: * Location of simulated fire origin; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. In addition, the facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months. The need to ensure unannounced fire drills were conducted every other month and included all required components and fire and life safety instruction was provided to staff on alternate months, was discussed with Staff 1 (Regional Director) on 01/05/22. She acknowledged the findings.

1 - Fire drill form with appropriate Fire Life Safety requirements to be reviewed with maintenance director 2 - Fire drills to be conducted on company standardized forms which address all needed requirements per OAR 3 - Fire drills/training to be reviewed during internal QA meeting to assure compliance ED responsible

Based on interview and record review, it was determined the facility failed to ensure fire and life safety training included all required components. Findings include but are not limited to: Facility fire and life safety records dated 07/2021 through 10/2021, were reviewed on 01/05/22 and revealed the facility lacked documented evidence of the following: * Evidence alternate routes were used during fire drills; and * Staff provided fire evacuation assistance to residents from the building to a designated point of safety. The need to ensure fire and life safety training included all required components was discussed with Staff 1 (Regional Director) on 01/05/22. She acknowledged the findings.

1 - Fire drill form with appropriate Fire Life Safety requirements to be reviewed with maintenance director 2 - Fire drills to be conducted on company standardized forms which address all needed requirements per OAR 3 - Fire drills/training to be reviewed during internal QA meeting to assure compliance ED responsible

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were clean and in good repair. Findings include, but are not limited to: During a tour of the facility on 01/04/22, multiple resident rooms including, but not limited to, 209 and 231, had stains, black marks and worn carpets. A tour of the environment was conducted with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings and stated the facility had identified a list of rooms needing carpet replacement and the facility planned to do the replacements.

1) Rooms 209 and 231 resideng carpet has been identified for cleaning, repair or replacement.   2) Administrator, maintenance and housekeeping will do a weekly walkthrough utilizing the environmental QA form.Work order binder to be brought to stand up daily to review and assure items are being addressed 3) The weekly audits will be reviewed at QA for trends and QAPI opportunities 4) ED responsible

Based on observation and interview, it was determined the facility failed to ensure exit door alarms were functioning to alert staff when residents exited the RCF and provided a working call system in toilet and bathing facilities used by residents and visitors. Findings include, but are not limited to: 1. Observations during the survey revealed multiple exit doors in the RCF had alarms installed but were not functioning. 2. Observation of the call system in shower rooms and visitor bathrooms on the second floor of the building showed the pull cords did not alert staff that they were activated. A interview with direct care staff on 01/06/22 revealed the call lights in the shower rooms and visitor bathrooms did not alert staff or anyone in the building so staff could respond. The need for a working call system and exit door alarms was discussed with Staff 1 (Regional Director) during a walk through of the facility on 01/06/22. She acknowledged the findings.

1 - Call system conversion in RCF to address exit door alarms, shower rooms and visitor bathrooms to I-Alert system 2 - Inservice of staff on the use of iAlert monitoring of exit doors, shower, and visitor bathrooms to occur. 3 - Review of call light times in shower rooms, exit doors and visitor bathrooms reviewed daily and monthly in internal QA meetings ED responsible

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 231, C 240, C 370, C 372, C 420, C 422, C 513 and C 555.

See POC for C231, C240, C370, C372, C420, C422 C513, C555

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 270, C 303, C 305, C 310, C 315 and C 325.

SEE POC for C252, C260, C270, C303, C305, C310, C315 and C325

Based on observation, interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in residents' service plans for 2 of  3 sampled residents (#s 2 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the memory care unit in December 2021 with diagnoses including dementia. Interviews with staff and the resident were conducted. Resident 2's medical record was reviewed. On 01/05/22 at 10:05 am, Staff 10 (MC CG) confirmed the resident was on a pureed diet, needed meal assistance and preferred to take meals in his/her room. Staff 10 went on to report Resident 2 did not like the pureed diet and after taking one to two bites, often refused to eat the remainder of the meal. Staff 10 confirmed the resident was on nutritional supplements, received them up to three times a day and usually finished approximately one third of the serving. On 01/05/22 at approximately 1:30 pm, Staff 1 (Regional Director) stated she was on the unit on 01/02/22 during dinner and the resident ate about half of the creamy potato soup with the meal assistance she provided. On 01/05/22 at approximately 1:45 pm, Resident 2 confirmed not liking the food and s/he preferred soup and sandwiches. Resident 2's 12/13/21 through 01/04/22 MARs were reviewed and revealed a nutritional supplement was added on 12/23/21 with directions to staff to offer if the resident's meal intake was less than 50%. All entries were blank. There was no documented evidence of the resident's food preferences, where the resident preferred to eat meals and the meal assistance s/he required in the resident's service plan. 2. Resident 5 was admitted to the memory care unit in April 2021 with diagnoses including dementia. Observations were made, an interview with the resident's family member was conducted and medical records were reviewed. On 01/04/22 at 11:22 am, a staff member was observed feeding Resident 5 a creamy, thick substance from a four ounce clear plastic container. On 01/05/22 at 1:58 pm, the resident's family member reported the resident being lactose intolerant, historically not liking eggs and requested the facility to provide rice to the resident. The family member did not believe rice was provided since the request had been made. The family member also stated they took Resident 5 out to a meal each Sunday, the resident had a "healthy appetite" and usually finished all of the food, without assistance, on his/her plate. The family member went on to report the resident's current favorite foods. None of which were identified on the resident's current service plan. There was no documented evidence of the resident's food and beverage preferences. The information in Resident 5's service plan was not accurate pertaining to where the resident preferred to eat meals and there was no indication Resident 5 needed meal assistance. The need to ensure residents' nutrition plans were individualized was discussed with Staff 1 and Staff 2 (RN) on 01/06/22. They acknowledged the findings.

1 - Resident 2 and 5 SP updated to address their food preferences. 2 - All resident service plans to address food likes, dislikes and meal preference - including assistance needed and where they prefer to eat. 3 - SP to be reviewed and updated quarterly unless otherwise needed, and preferences to be reviewed at that time with SP planning team ED, DHS/RN, RCCs responsible

Based on observation and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 5) whose records were reviewed. Findings include, but are not limited to: Resident 1, 2 and 5's service plans offered some historical information about the residents, however the facility had not fully evaluated the resident's: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents to participate in group activities or assist with providing more individualized activities. The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

1 - Resident 1, 2 ,5  service plans corrected with an individualized activity plan as outlined in OAR 2 - Activity plans/evaluations will be updated quarterly per service planning process which will include addressing current ability to participate in activites, current preferences, etc 3 - Service Plans/Evals due are reviewed daily during 24 hour process . Will audit 2 activity service plans monthly as part of ongoing QA process ED and Activity Director responsible

Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked out of their rooms. Findings include, but are not limited to: During the survey, observations of resident rooms revealed multiple rooms were locked from the outside, preventing residents from entering their rooms without assistance from staff. Caregiving staff each carried a key which could open residents' rooms. On 01/04/22, an unsampled resident was observed trying to open their apartment door and stating, "it's locked, can you open it?" The resident was observed seeking out staff to unlock his/her door. On 01/06/22, the need to ensure residents were not locked outside their rooms was discussed with with Staff 1 (Regional Director). She acknowledged the findings.

1 - Resident service plans will be updated to reflect preference and ability for door to be locked in their presence or absence. 2 - Residents with the ability to maintain use of a key will be provided a key or mechanism for a key for their rooms. Evaluations will be completed and/or preferences made known in their service plan 3 - Quarterly as part of the service planning process ED responsible

The findings of the re-licensure survey conducted 01/04/22 through 01/06/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 01/06/22, conducted 04/04/22 through 04/05/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.