Guardian Angel Homes Memory Care

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs;

Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs for multiple sampled and unsampled residents. Findings include, but are not limited to: During the re-licensure survey from 05/04/26 through 05/06/26, observations showed there was a lack of scheduled and unscheduled activities provided for residents living in the MCC. Throughout each day of the survey, care staff turned on cartoon/animated movies in the common area of the unit - only one or two residents appeared to watch or pay attention to what was on the television. Review of the 05/2026 activity calendar showed the following activities were scheduled on Monday 05/04/26: 8:30 am Keep Out Challenge in Ranch House; 9:15 am Keep Out Challenge in Tuscan House; 10:00 am Bingo (Rose Arbor Dining); 1:00 pm Kentucky Derby Bingo in Ranch House; 2:00 pm Kentucky Derby Bingo in Tuscan House; 3:00 pm Hidden Birds Game (Rose Arbor); and 3:45 pm Kentucky Derby Horse Race (Rose Arbor). During an interview on 05/05/26 from 2:30 pm to 3:08 pm, Staff 7 (Activity Director) and Staff 8 (Activities Assistant) reported Bingo was the only activity that happened in the Tuscan House on Monday 05/04/26. On 05/05/26 the following activities were scheduled: Tequila Karaoke and Cinco De Mayo Trivia with “no set scheduled time for activities”. In the Tuscan House on 05/05/26 from 10:38 am to1:05 pm, there were no activities observed. Residents were observed sitting in the dining room, in their rooms, or watching television in the common area. In the Ranch House unit on 05/05/26 from 10:00 am to 2:30 pm, there were no activities observed. Residents were observed sitting in the dining room, in their rooms, or watching television in the common area. During an observation and interview on 05/05/26 from 2:30 pm to 3:08 pm, with Staff 7 and Staff 8, the following was identified: • Staff 7 and Staff 8 were seen in the assisted living gathering paper crossword printouts and drinks for residents, which was not the scheduled Tequila Karaoke activity in the MCC. • Staff 7 reported on Tuesdays and Thursdays, she and the other activity staff were scheduled to take residents to medical appointments. “When we have appointments, we can’t provide activities for the other residents.” Staff 7 reported there was one medical appointment scheduled for 05/05/26. • Staff 7 further reported there were no activity staff scheduled on Saturdays and Sundays. She stated, “I expect caregivers to do the activities.” During an interview on 05/05/26 at 1:50 pm Staff 11 (CG) and Staff 14 (CG), stated they were given no instructions to conduct activities with the MCC residents. The staff members were shown an activity book on the unit with ideas for group or individual activities. The staff members identified activity items kept in a cabinet but re-stated they were given no instructions to use the activity book or activity items available. Staff 11 stated sometimes they played music but mostly had movies playing for the residents. The need to ensure the facility provided a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (LPN) on 05/06/26 at 1:00 pm. They acknowledged the findings.

1. During activity staff absences the floor staff will be given activity tasks to be completed during their shifts. These activities will be on the care giver task list. Included on the task list will be activity ideas and where to find needed supplies for each activity choice. 2. Re-education will be given to current employees and education on the task list additions. New hires will go through an activity orientation where the importance of activities is emphasized along with training on the task list and location of activity supplies. 3. The activity director, the activity assistant and the administrator will meet weekly to monitor the progress of the POC. 4. The activity director and administrator are responsible for seeing that the POC is being followed.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs;

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

Based on interview and record review, it was determined the facility failed to ensure the initial resident evaluation contained all required elements for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 was previously living in the assisted living facility, experienced a change of condition related to cognitive decline, and was transferred to the MCC in 03/2026 with diagnoses including vascular dementia. The 03/23/26 to 05/04/26 clinical record was reviewed. The following was identified: The facility used a change of condition evaluation rather than an initial evaluation for Resident 1’s admission into the MCC, therefore, the evaluation failed to address the following required elements: * Preferred name, pronouns, and gender identity; * Visits to health practitioners, emergency room, hospital, or nursing facility in the past 12 months; * Effective non-drug interventions for mental health issues; * Personality: including how the person copes with change or challenging situations; * Complex medication regimen; * History of dehydration; * Recent losses; and * Unsuccessful prior placements. The need to ensure the initial evaluation contained information addressing all required elements was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (LPN) on 05/06/26 at 4:15 pm. They acknowledged the findings.

1. The LN will ensure that a completely new move in evaluation is completed for all admissions. Including residents moving from the on-campus AL to memory care prior to the move. 2. A clinical team admission or move to on-campus memory care flow chart has been developed for all clinical staff to follow. Clinical staff will also follow our current admissions policy. 3. Microsoft Teams will be utilized for each new resident to keep track of each admission task and assigned to each LN as well as reviewing each new resident’s file at their 30-day evaluation. 4. The RN and Administrator will be responsible for ensuring that the policy will be followed and all evaluations will be completed prior to admission.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements, including name, pronouns, and gender identity, for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to C 252.

1. We have added all missing elements to the evaluation form for each resident. Staff that will be evaluating potential residents will complete the form without leaving any section blank. All elements of this form will be added to the careplan prior to the admission date. 2. We have added all missing elements to the evaluation form for each resident. 3. Microsoft Teams will be utilized for each new resident to keep track of each admission task and assigned to each LN as well as reviewing each new resident’s file at their 30-day evaluation. 4. The RN and Administrator will be responsible for ensuring that the policy will be followed and all evaluations will be completed prior to admission.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity.

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: C 242.

See provider response to C 242

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 have documented evidence of required pre-service dementia training completed prior to beginning job duties and demonstrated competency in assigned duties within 30 days of hire for 3 of 3 sampled newly hired direct care staff (#s 9, 12, and 13). Findings include, but are not limited to: Training records: for Staff 9 (MT/CG), Staff 12 (CG), and Staff 13 (CG), hired 03/03/26, 02/16/26, and 03/09/26, respectively, were reviewed on 05/05/26. The following deficiencies were identified: 1. There was no documented evidence Staff 9, Staff 12, and Staff 13 completed additional pre-service dementia training in one or more of the following dementia training topics: * Environmental Factors that are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); and * Use of supportive devices with restraining qualities in memory care communities. b. There was no documented evidence Staff 9, Staff 12, and Staff 13 had knowledge and performance demonstrated within 30 days of hire in the following required areas: * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (Administrator), Staff 2 (Health Services Director/RN), and Staff 3 (LPN) on 05/06/26 at 2:10 pm. They acknowledged the findings.

1. The updated training template through our supplier, Relias, has been created and implemented. 2. Moving forward the staffing director will look for training updates quarterly as well as signing up for administrator alerts to ensure up to date training is being implemented. 3. This will be evaluated quarterly and as needed when new rules come into effect. 4. The Business office manager, the staffing director and the administrator will be responsible for ensuring compliance.

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 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

Based on 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 252.

See provider response to C 252

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and documented in the resident's service plan for 2 of 2 residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to: Resident's 2 and 3's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator), Staff 2 (Health Services Director/RN), and Staff 3 (LPN) on 05/06/26 at 2:10 pm. They acknowledged the findings.

1. Initial nutritional evaluations will be made and reviewed for effectiveness. A short term monitor will be placed initially and with any change to dietary needs or preferences. 2. The dietary manager will be educated and will work closely with the clinical staff to ensure all resident dietary and hydration needs are being met. 3. All diet changes will be reviewed monthly during the interdisciplinary weight meeting. 4. The LN, dietary manager and the administrator will be responsible for all completion and monitoring for this correction.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

Based on observation, interview, and record review, it was determined the facility failed to develop individual activity plans that were based on activity evaluations for 2 of 2 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s service plans were reviewed, and observations were made of the residents. The following was identified: Though the service plans included some information about activity preferences, there was no documented evidence of an evaluation that addressed the following required elements: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. On 05/05/26 at 2:30 pm, Staff 7 (Activities Director) verified neither she nor her staff had evaluated the residents that included all of the above listed requirements. She also confirmed that an individual activity plan had not been developed for each resident. The need to develop individualized activity plans that were based on an evaluation of the resident's activity interests, abilities, and needs was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (LPN) on 05/06/26 at 1:00 pm. They acknowledged the findings.

1. The activity director has been educated on how to complete the activity evaluation/ life story upon admission. We are exploring the ability to create a separate activity plan for each resident as part of our current system. 2. The activity director will meet with residents upon admission to review their current life story obtained a part of the admission process. 3. The activity director will review upon the 30 day review and every 90 days. 4. The activity director and administrator will ensure compliance.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

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).

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: 1. Observations of the main kitchen were made on 11/24/25 at 11:40 am through 1:20 pm. a. The following areas were in need of cleaning: ? Food particles and splatter on the interior surfaces of the microwave; ? Food spills and debris on the lower shelves of the prep table and service line; ? Black matter and hard water build-up on the water line inside the ice maker; ? Black matter on walls around the warewasher and sink, as well as the escutcheon and faucet of the three-compartment sink; ? Black matter and dust build-up on the warewasher vent and hood interior; ? Dust build-up on the underside of the sink in the warewashing area; ? Rust and corrosion on the warewasher, pipes and valve, thermostat, electrical box; and ? Black matter on the blade and housing of industrial can opener. b. The following areas were in need of repair: ? A square opening had been cut into the kitchen wall to vent a portable AC machine; the wall was not sealed around the hose, exposing the kitchen to the exterior of the building where rodents and insects could potentially gain access; and ? The flange around the food disposal opening on the counter in the warewashing room was uncleanable. c. Multiple food items in dry storage room and on the lower shelf of the prep station were found open and/or uncovered/protected from potential contamination. d. The warewasher was observed during multiple cycles, and did not reach 180 degrees Fahrenheit during sanitization rinse cycle. Staff were aware of this and were using the three-compartment sink with automated sanitizer solution; the dispenser did not pour strong enough sanitizer concentration when measured with test strips. A technician corrected the concentration levels, and staff demonstrated adequate sanitizing levels with test strips. At 2:35 pm on 11/24/25, the Administrator (Staff 1) reported all dishes and cookware would be washed and sanitized in the three-compartment sink until the warewasher was repaired or replaced. All staff would receive training on proper sanitization procedures and use of test strips. 2. Observations of the Tuscan MCC kitchenette were made on 11/24/25 at 1:25 pm. a. The following areas were in need of cleaning: ? Black matter in the seams between the countertop and undermount sink surface on the dishwashing and handwashing sinks; and ? Black matter and stains in the interior of the base cabinet to the right of the dish machine. b. The following areas were in need of repair: ? Cabinet faces were scratched and worn, exposing bare wood along multiple base cabinet doors and frame pieces surrounding entry doors to the kitchenette; ? Two base cabinet doors were loose on their hinges and were unable to close completely; ? The dish machine did not reach 180 degrees Fahrenheit during the sanitization rinse cycle. Staff 1 reported all dishes for the Tuscan House would be washed in their two compartment sink and sanitized in a tub of bleach solution until the dishwasher was repaired or replaced. All staff would receive training on proper sanitization procedures and use of test strips. c. Additional observations: ? Two trays of uncovered glasses of water and juice were observed in the refrigerator; ? Multiple covered plates, bags and containers of food in the refrigerator were unlabeled; ? After washing, silverware was left on the countertop to dry, unprotected from potential contamination; ? Tables in the dining room adjacent to the kitchenette revealed scraped and gouged wooden legs and worn table top edges that exposed bare wood, making them uncleanable. 3. Observations of the Ranch House were made on 11/24/25 at 2:05 pm. a. The following areas were in need of cleaning: ? Food splatter and dust on cabinet fronts on base cabinets near the trash cans and serving station. b. The following areas needed repair: ? Caulk was separated from the dishwashing sink at the counter seam; the remaining caulk was lined with black matter. c. Additional observations: ? Uncovered glasses of water and juice were observed in the refrigerator; ? Multiple covered pans, plates and baggies of food were unlabeled; and ? Silverware was stacked in a utensil holder with food surfaces facing up, unprotected from potential contamination. The above findings were reviewed with Staff 1 and the Dietary Director (Staff 2) on 11/24/25 at 3:10 pm. They acknowledged the areas in need of correction. Aging and People with Disabilities Safety, Oversight and Quality PO Box 14530 Salem, Oregon 97309 Phone: 503-373-0200 Fax: 503-373-0222 Department of Human Services Statement of Deficiencies and Plan of Correction Provider/Supplier/CLIA Identification Number: 50M428 Date Survey Completed: GUARDIAN ANGEL HOMES MEMORY CARE 540 NW 12TH ST HERMISTON, Oregon 97838 Umatilla 50M428 - KIT008044 - Visit of . 50M428 - KIT008044 - Visit of .

Maintenance and dietary staff will collaborate to identify appropriate cleaning agents and approved cleaning techniques to effectively remove black residue observed around countertops, undermount sink areas, the dishwasher, the handwashing station, and surrounding cabinetry. The dietary manager and dietary staff will routinely monitor these areas throughout each day to ensure cleanliness is maintained and to prevent reoccurrence. The dietary manager will notify and work closely with maintenance staff to assess the condition of the kitchen and dining areas requiring repair or refurbishment. Affected areas include cabinet faces and door frames, loose or damaged hardware in the kitchen, and dining room furnishings such as table legs and edges. Dietary and house staff will assist in monitoring these areas and will promptly inform maintenance of any future repair needs. The dishwashing machine is currently not reaching the required 180°F necessary for proper sanitation. The dietary manager will work with maintenance staff to assess and correct this issue and will monitor the equipment for any future reoccurrence. In the interim, the dietary manager will train and support dietary and house staff on proper manual sanitization procedures, including the use of the three-sink method, bleach solutions in tubs, and appropriate use of sanitizer test strips. Refrigerators will be monitored daily by dietary and house staff to ensure all food and beverages are properly covered, labeled, and stored to prevent contamination. The dietary manager will reinforce the importance of food safety, food contamination prevention, and proper labeling practices to ensure staff compliance. The dietary manager will remind and educate staff on proper post-washing handling of silverware to prevent contamination. Corrective instruction will be provided as needed, and compliance will be monitored. At the Ranch House location, observations identified similar concerns around the sink area. The dietary manager will coordinate with maintenance to address needed repairs and to determine appropriate cleaning solutions for removing black residue. Dietary and house staff will continue to monitor these areas, apply proper cleaning techniques, and keep maintenance informed to prevent reoccurrence. The dietary manager will continue to reinforce food safety knowledge, including proper food covering and labeling practices, to prevent contamination. Dietary and house staff will jointly monitor food storage and refrigeration areas to ensure ongoing compliance with established procedures. Lastly, the dietary manager will remind house staff of proper silverware sanitation procedures and will monitor practices in collaboration with house staff to ensure silverware is handled and stored correctly at all times.

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 411-054-0030 (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).

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: 1. Observations of the main kitchen were made on 03/23/26 at 10:50 am through 11:20 am. a. The following areas were in need of cleaning: * Food particles and splatter on the interior surfaces of the microwave; * Black and pink matter and hard water build-up on the water line inside the ice maker; * Black matter on walls around the warewasher and sink, as well as the escutcheon and faucet of the three-compartment sink; * Black matter and dust build-up on the warewasher vent and hood interior; * Dust build-up on the underside of the sink in the warewashing area; * Rust and corrosion on the warewasher, pipes and valve, thermostat, and electrical box; and * Black matter on the blade and housing of industrial can opener. b. The following areas needed repair: * The flange around the food disposal opening on the counter in the warewashing room was uncleanable; and * The lower shelf of the prep table near the serving line was broken and one edge was resting on the floor. c. The warewasher was observed during multiple cycles and did not reach 180 degrees Fahrenheit during the sanitization rinse cycle. At 10:55 am on 03/23/26, Staff 9 (Dietary Director) stated staff use the three-compartment sink to wash, rinse, and sanitize dishes that went through the warewasher for the purpose of cleaning food from the dishware. She stated the facility was out of test strips. At 12:10 pm on 03/23/26, Staff 1 (Administrator) stated she was unaware kitchen staff had not been using test strips in the three-compartment sink or to test cleaning solutions. She confirmed Staff 9 had ordered test strips from Sysco and stated training for staff in proper use of test strips would be conducted once they arrived the next day. 2. Observations of the Tuscan MCC kitchenette were made on 03/23/26 at 11:20 am. a. The following areas were in need of cleaning: * Black matter in the seams between the countertop and undermount sink surface on the dishwashing and handwashing sinks; and * Black matter and stains in the interior of the base cabinet to the right of the dish machine. b. The following areas were in need of repair: * Cabinet faces were scratched and worn, exposing bare wood along multiple base cabinet doors and frame pieces surrounding entry doors to the kitchenette; * Two base cabinet doors were loose on their hinges and were unable to close completely; * The dish machine did not reach 180 degrees Fahrenheit during the sanitization rinse cycle. Staff 9 reported all dishes for the Tuscan House were hand-washed in their two-compartment sink and sanitized in a tub of bleach solution. There were no test strips to ensure disinfectant solutions were at the required concentration for proper infection control. c. Additional observations: * Tables in the dining room adjacent to the kitchenette revealed scraped and gouged wooden legs, making them uncleanable. 3. Observations of the Ranch House kitchenette were made on 03/23/26 at 11:35 am. a. The following areas were in need of cleaning: * Food splatter and dust on cabinet fronts on base cabinets near the trash cans and serving station. b. The following areas needed repair: * Caulk was separated from the dishwashing sink at the counter seam; the remaining caulk was lined with black matter. The above findings were reviewed with Staff 1 and Staff 9 on 03/23/26 at 12:10 pm. They acknowledged the areas in need of correction.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333150-000. This is a repeat citation. Findings include, but are not limited to: All cleaning and repairs cited in the SOD were addressed before the end of the business day on the inspection date. A daily and weekly cleaning duty list has been updated with more detail to include more detailed instructions for each area of concern. Also, specifically assigning cleaning tasks to indiviual kitchen staff to ensure accountability. Staff are required to initial their list upon completion and then notify the kitchen manager of the completion verbally or by text. In the memory care homes kitchens the staff on shift during NOC have task lists for cleaning the kitchens. Dietary staff will audit the kitchens for all areas and ensure the tasks are done daily. The dietary staff will keep the RCC informed of any missed tasks and floor staff will be held accountable. The kitchen manager will monitor all kitchen areas in AL and MC for cleanliness throughout the day through observation and formal audits 3 times weekly based on the cleaning checklist and floor staff cleaning task list. The kitchen manager with perform the daily and weekly audits and report to the administrator. The following areas needed repair: * The flange around the food disposal opening on the counter in the warewashing room was uncleanable; and the lower shelf of the prep table near the serving line was broken and one edge was resting on the floor. The maintenance department will replace the flange that is over the food disposal to ensure a better fit and a cleanable surface. The prep table will be repaired by the maintenance department or replaced if repair is not possible. The warewashers will be replaced in the memory care but until then the staff will use the three sink method. Maintenance will clean and recaulk all sinks in food prep areas and hand washing sinks. They will also address the stains in the cabinet by the dish machine. The warewasher was observed during multiple cycles and did not reach 180 degrees Fahrenheit during the sanitization rinse cycle. At 10:55 am on 03/23/26, Staff 9 (Dietary Director) stated staff use the three-compartment sink to wash, rinse, and sanitize dishes that went through the warewasher for the purpose of cleaning food from the dishware. She stated the facility was out of test strips. At 12:10 pm on 03/23/26, Staff 1 (Administrator) stated she was unaware kitchen staff had not been using test strips in the three-compartment sink or to test cleaning solutions. She confirmed Staff 9 had ordered test strips from Sysco, and stated training for staff in proper use of test strips would be conducted once they arrived the next day. Test strips were ordered and received. The warewasher will be replaced but until it arrives the kitchen will use the three sink method to clean and sanitize dishes and utensils. The dietary manager trained the staff on the proper three sink method and training on using the sanitizing test strips as well as the temp strips for testing the warewasher. 2. Observations of the Tuscan MCC kitchenette were made on 03/23/26 at 11:20 am. a. Maintenance will clean and recaulk all sinks in food prep areas and hand washing sinks. They will also address the stain on the cabinet near the warewasher. b. Cabinets- the maintenance department will repair the cabinets that are still strucurally sound and then replace the cabinets that require replacement. The maintenance department will refinish or replace damaged tables. 3. Observations of the Ranch House kitchenette were made on 03/23/26 at 11:35 am. a. All cleaning is on a daily and weekly schedule. Dietary staff to audit all cleaning in the memory care kitchens. c. The warewashers will be replaced asap. In the mean time the staff will use the three sink method. All testing of solution will be monitored by the kitchen manager.

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, 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 C240.

see C 240

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 411-057-0140(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. This is a repeat citation. Findings include, but are not limited to: Refer to C240.

Refer to C240.

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

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 interview, observation, and record review, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

Refer to C240.

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 interview and record review conducted during a site visit on 07/17/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: In an interview on 07/17/25 Staff 1 (Executive Director) and Staff 2 (Business Office Manager) indicated that the facility used a proprietary ABST called Bluestep which both staff stated should have been submitted to the department for approval. The facility was unable to provide any documentation to verify the proprietary ABST had been submitted to the department. In review of the ABST document, there was no indication of when the last time each resident had been updated. The facility failed to ensure the proprietary ABST had been submitted to the department for review prior to implementation, and the facility failed to ensure the proprietary ABST met the required element of identifying the date the resident's ABST evaluation was last completed. Findings were reviewed and acknowledged by Staff 1, Staff 2 and Staff 3 (LN) on 07/17/25. Based on interview and record review conducted during a site visit on 07/17/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: In an interview on 07/17/25 Staff 1 (Executive Director) and Staff 2 (Business Office Manager) indicated that the facility used a proprietary ABST called Bluestep which both staff stated should have been submitted to the department for approval. The facility was unable to provide any documentation to verify the proprietary ABST had been submitted to the department. In review of the ABST document, there was no indication of when the last time each resident had been updated. The facility failed to ensure the proprietary ABST had been submitted to the department for review prior to implementation, and the facility failed to ensure the proprietary ABST met the required element of identifying the date the resident's ABST evaluation was last completed. Findings were reviewed and acknowledged by Staff 1, Staff 2 and Staff 3 (LN) on 07/17/25.

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).

Based on observation, and interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: 1. Observations of the facility main kitchen, food storage areas, food preparation, and food service on 11/04/24 revealed: * Splatters, spills, and drips noted on: - Food storage bins under the tray-line; - Shelving throughout the kitchen; - Exterior of the range; - Interior of the microwave; - The stand mixer; - The free standing air conditioner; - Walls and equipment in the dishwashing area including the vent above the dish machine; * Black matter noted on the can opener blade; * Dust and debris was built up on metal storage shelves throughout the kitchen; * Dust and debris noted on cage of rotating fans blowing onto the food preparation area; * Multiple bottles and jars of foods noted to require refrigeration were left in an un-refrigerated food storage area; * Undated food items and food items with dates older than seven days were noted in the reach in refrigerator; * Packaged foods were not dated when opened; * Raw eggs were stored above leafy greens; * Boxes were stored on the floor in the walk in refrigerator; * The cove-base and flooring was broken, cracked, and damaged with an accumulation of debris; and * The screen on the back entrance to the kitchen was damaged allowing the entrance of flies and pests. The commercial high temperature dish machine was observed in operation multiple times. It was not reaching the specified temperature required for the sanitizing rinse cycle. There was no evidence of consistently monitoring the temperatures of cooked foods, refrigerator temperatures, and the dish machine temperatures. The kitchen was toured with Staff 2 (Dietary Manager) and Staff 4 (Maintenance Director). Staff 2 reported dishes would be washed and sanitized in the triple pot sink area until the dish machine was operating correctly. 2. Observations of the facility Memory Care kitchens, food storage areas, food preparation, and food service on 11/04/24 revealed: * Splatters, spills, and drips noted: - Inside drawers, cupboards, and on shelving; and - Interior of the reach refrigerators and freezers including in the door seals. A plate of food was left in the microwave of Country House. The front of the lower drawer to the left of the sink was broken off in Tuscan House. The dish sanitizers in both Tuscan and Country Houses were not operating per specifications. There was no detergent, rinse aid, or sanitizer in use, the hosing for each chemical was left lying under the kitchen sinks. Staff 2 reported dishes would be washed and sanitized in the triple pot sink area until the dish machine was operating correctly. The safe food handling and storage concerns areas in need of cleaning and repair were reviewed with Staff 2 and Staff 4. They acknowledged the findings.

MC Kitchen Immediate Actions: All of the Splatters, spills, drips were cleaned the day of the inspection. Staff was educated regarding the food left in the microwave and the food was removed and disposed of. The front drawer that was off in the Tuscan house was repaired. Washing and sanitizing dishes has been changed to the 3 sink method until equipment can be repaired or replaced in all homes. Near future Actions: The sanitizers will be replaced System Correction: On going cleaning daily cleaning task list to be completed by kitchen staff will be reviewed for any correction or additions relating to the findings. These tasks will be completed before the end of the day every day. Weekly deep cleaning of all areas will be added in addition to the daily task list and assigned to specific persons to allow follow up and accountability. The night shift task list will be reviewed and updated and additional education on food safety will be developed and scheduled. Monthly Continued training will be developed and assigned to kitchen staff on a rotating schedule regarding cleaning, food safety, temperature monitoring and documenting, etc. Audit/Follow up/Responsible Party: The dietary manager will inspect all areas 5 days a week Monday - Friday for compliance. The administrator will do a bi weekly (every 2 week) audit of all areas. The disiplinary policies will be followed to ensure accountability.

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).

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the kitchen on 03/13/25 showed the following areas needed cleaning or repair. * Flooring throughout the kitchen had large black/gray stains, gouges, severe cracked edges and corners, corners were pulled away from the edges of the walls in several areas, chunks of the top layer of linoleum were missing and seams were pulling apart which created gaps in the floor. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Dietary Manager) on 03/13/25. The staff acknowledged the findings.

Replacement of the commercial kitchen flooring: A quote, product selection and replacement will take place as soon as it can be scheduled. All attempts will be made to meet the deadline given by CBC.

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).

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observation of the kitchen on 06/04/25 showed the following areas needed cleaning or repair: The floor throughout the kitchen had large black/gray stains, gouges, and severe cracked edges and corners. The corners were pulled away from the edges or the walls in several areas, chunks of the top layer of linoleum were missing, and seams were pulling apart which created gaps in the floor. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Dietary Manager) on 06/04/25. The staff acknowledged the findings.

Replacement of the commercial kitchen flooring: We have received the quote and have the product waiting. Replacement will take place as soon as it can be scheduled. All attempts will be made to meet the deadline given by CBC.

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, 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 240.

Refer to C240.

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

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

See 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.

see C 240

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 411-054-0105 (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, 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 C240.

See C240

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.

see C 240

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 interview and record review, it was determined the facility failed to ensure the initial move-in evaluation contained all required elements for 1 of 1 sampled resident (#4) who was recently admitted to the facility. Findings include, but are not limited to: Resident 4 was admitted to the facility in 01/2023. Review of the initial evaluation dated 01/30/23 revealed the following elements were missing: * Spiritual, cultural preferences & traditions; * Personality: including how the person copes with change or challenging situations; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature. The need to ensure the initial evaluation included all of the required elements was discussed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN). The findings were acknowledged.

C 252 OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation 1.The leadership team has reviewed the OARs for Resident Move-in and evaluation and cross referenced the internal tools to ensure all OARs are captured on the pre-admit, admission, and evaluation forms. The internal systems, processes, policies, procedures, and protocols were reviewed by the leadership team to ensure ongoing compliance. The Health Services Director, Administrator, and nursing support team reviewed focused education for support and compliance. 2. The Administrator and Health Services Director will ensure ongoing compliance, following the required OARs, for all aspects of the Resident Move-in and evaluation requirements. The pre-admit, admission, and ongoing evaluation forms have been cross-referenced, updated, and the root cause for incomplete data collection was identified. 3. The Health Services Director will routinely audit and the Administrator will spot audit on a monthly basis. 4. The Health Services Director and Administrator will maintain ongoing compliance.

Based on interview and record review, it was determined the facility failed to monitor each resident consistent with his or her evaluated needs and service plan, for 3 of 3 sampled residents (#s 1, 2 and 3) who required monitoring following multiple changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the MCC in 10/2022 with diagnoses including vascular dementia with behavioral disturbance. Resident 1's progress notes, short term monitoring documentation, service plan and incident reports were reviewed during the survey. a. Between 01/29/23 and 03/26/23, the resident had nine falls. For five of the nine falls, there was no documented evidence the facility followed up to monitor whether service-planned interventions were being followed at the time of the falls, and whether the interventions were effective or that new interventions needed to be developed and implemented. b. Between 01/29/23 and 03/26/23, the resident had three physical altercations with peers. For all three of the altercations, there was no documented evidence the facility followed up to monitor whether service-planned interventions were being followed at the time of the incidents, and whether the interventions were effective or that new interventions needed to be developed and implemented. The need for the facility to document that it was monitoring a resident's service plan following changes of condition was reviewed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN) on 04/07/23. They acknowledged the lack of monitoring. 2. Resident 2 was admitted to the MCC in 10/2022 with diagnoses including unspecified dementia, psychotic disturbance and mood disturbance. Resident 2's progress notes, short term monitoring documentation, service plan and incident reports were reviewed during the survey. Between 01/31/23 and 04/03/23, the resident had five incidents where the resident was found on the floor or dropped his/her weight while staff were transferring him/her and had to be lowered to the ground. * For three of the incidents, there was no documented evidence the facility followed up to monitor whether service-planned interventions were being followed at the time of the incidents, and whether the interventions were effective or that new interventions needed to be developed and implemented. * For two of the incidents, the person who reviewed what had happened documented new interventions on the incident report form. However, there was no documented evidence the new interventions were added to the resident's service plan and communicated to staff. The need for the facility to document that it was monitoring a resident's service plan following changes of condition, and adding new interventions to the service plan as needed was reviewed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN) on 04/07/23. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 10/2021 with diagnoses including dementia and type 2 diabetes. Resident 3's progress notes, short term monitoring documentation, service plan and incident reports were reviewed during the survey. Between 02/04/23 and 04/01/23, Resident 3 had three incidents where the resident had unwitnessed falls in his/her room and one fall that was witnessed by staff. For the four incidents, there was no documented evidence the facility followed up to monitor whether service-planned interventions were being followed at the time of the incidents, and whether the interventions were effective or that new interventions needed to be developed and implemented. The need for the facility to document that it was monitoring a resident's service plan following changes of condition, and adding new interventions to the service plan as needed, was reviewed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN) on 04/07/23. They acknowledged the findings.

C 270 OAR 411-054-0040 (1-2) Change of Condition and Monitoring 1. The leadership team reviewed the OARs for resident Change of Condition (COC) and Monitoring and evaluated systemic changes to improve the required and best practice documentation. The team also discussed strategies for continued education. Root cause analysis was reviewed using the who ,what when, where, how, and the 5 Why's for incidents, accidents, and human expressions (behaviors). A Care Coordination workgroup was created to provide interdisciplinary support. The Care Coordination team will utilize the same root cause tools. 2. The Health Services Director (HSD) will oversee the licensed nursing and Care Coordination teams and staff education following all OARS for COC and monitoring. The interdisciplinary Care Coordination workgroup will meet on a weekly basis to root cause, update, educate, and evaluate resident needs. 3. The Care Coordination workgroup will meet on a weekly basis to review all incidents and accidents. The Care Coordination team will meet twice weekly for service plan reviews, short term monitor reviews, and personalized expression plan reviews. 4. The HSD will ensure the Care Coordination team continues to meet twice weekly and weekly, per the interdisciplinary review schedule. In absence of the HSD the Administrator will faciliate the meeting and ensure scheduled meeting compliance. The licensed nurses and resident care coordinators will follow all COC and OARS on a daily individualized resident needs basis.

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code (OFC) every other month, and to provide fire and life safety instruction to staff on alternating months. Findings include, but are not limited to: Fire and life safety records were reviewed and Staff 5 (Maintenance Director) was interviewed on 04/05/23 and the following deficiencies were identified: There was no documented evidence the facility conducted fire drills every other month as required and provided fire and life safety instruction to staff on alternating months from fire drills. On 04/07/23, the need to ensure fire drills were conducted in accordance with the Oregon Fire Code (OFC), and staff instruction was provided on alternating months was discussed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN). They acknowledged the findings.

C 420 OAR 411-054-0090 Fire and Life Safety: Safety 1. The leadership team reviewed the OARs and OFC to create a sustainable system for compliance tracking and training. BlueStep electronic modifications were made by the IT department for improved efficiency, tracking, notifications, and compliance documentation. The maintenance team received focused education on their role and responsibilities, BlueStep electronic integration, staff education, and scheduling. 2. Fire Drills and staff education have been added to the tracking in Bluestep (the staff and resident EHR). The Maintenance Director and the Administrator will receive email alerts with the schedule alternating every other month. The Maintenance Director will document and upload a copy of the fire logs into BlueStep to increase transparency for auditing by the Administrator.   3.The Maintenance team will provide continous compliance and the Administrator will audit compliance on a monthly basis. 4. The Maintenance Director and Administrator will be responsible for upholding ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed within 24 hours of admission and were re-instructed at least annually in fire and life safety procedures as required by the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 04/05/23, Staff 5 (Maintenance Director) was interviewed, and the following deficiencies were identified: There was no documented evidence residents were instructed within 24 hours of admission and re-instructed annually on general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. On 04/07/23, the need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and re-instructed, at least annually, as required by the OFC was discussed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN). They acknowledged the findings.

C 422 OAR 411-054-0090 (5) Fire and Life safety: Training for Residents 1.The leadership team reviewed the OARs and OFC to create a sustainable system for compliance tracking and training. The maintenance team received focused education on their role and responsibilities for resident training, on fire and life safety within 24 hours of admission, and re-instruction, at least annually, and the electronic integration of BlueStep for their compliance documentation. 2. The Maintenance team will document resident training on admission and re-instruction, per the OARs and OFC directly into BlueStep.   3.The Maintenance team will provide continous compliance and the Administrator will audit compliance on a monthly basis. 4. The Maintenance Director and Administrator will be responsible for upholding ongoing compliance.

Based on observation and interview, it was determined the facility failed to ensure an exit door alarm or other acceptable system was provided for security purposes and to alert staff when residents exit the RCF. Findings include, but are not limited to: The facility was toured on 04/04/23. The MCC consisted of two separate buildings - the Tuscan House and the Ranch House. Each building had two exit doors which led outside - one main door in the front of the building and a side door. None of the doors had an operating system that would alert staff when a resident left the building. The need to provide an alarm or other system on the exit doors for each of the buildings was reviewed with Staff 5 (Maintenance Director) on 04/06/23. He stated the doors had sensors on them but acknowledged there was no current system that notified staff when the door was opened. The findings were reviewed with Staff 1 (ALF Administrator) on 04/07/23. She also acknowledged the findings.

C 555 OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, Cable 1.The leadership team reviewed the OARs and OFC to create a sustainable system for compliance tracking and training. The maintenance and direct care teams received focused education on their role and responsibilities for memory care home exit door, audible alarms, that must be in place to alert staff when residents are potentially exiting the building. 2. The Maintenance and direct care team will routinely check the exit door audible alarms. All staff will receive continued education to listen for the audible alarms and check the exits when sounded. The maintenance team will ensure operational and mechanical compliance and the direct care team will ensure safety responses. The Health Services Director (HSD) will oversee continued education for direct care. The Administrator will oversee maintenance education. The HSD and Administrator will oversee all staff continued education.   3.The Maintenance and direct care teams will provide continous compliance and the Administrator will spot audit routinely. 4. The Maintenance Director and Administrator will be responsible for upholding ongoing compliance.

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

Please refer to the POC for citation C 420, C 422 and C 555

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

Please refer to the POC for citation C 252 and C 270

Based on observation, interview and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3 and 4's records were reviewed, and observations were made during the survey. The current activity evaluations did not address the following required components: * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitation; * Adaptations needed to participate; and * Identification of activities for behavioral interventions. The current activity plans were not individualized to each resident based on their activity evaluation, and lacked instructions for staff on what activities to provide, how to provide them, when and how often. The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN) on 04/07/23. They acknowledged the findings.

Z164 OAR 411-057-0160(2d) Activities 1. The leadership team has reviewed the OARs for Resident Activity assessment and cross referenced the internal tools to ensure all OARs are captured on the internal systems, processes, policies, procedures, and protocols were reviewed by the leadership team to ensure ongoing compliance. IT to assist with including shadow text in all activity headings on the service plan to ensure requirements are captured including * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitation; * Adaptations needed to participate; and * Identification of activities for behavioral interventions.  The life stories will be completed for Residents 1,2,3, and 4 and the information collected included in their specific evaluation and careplan with instruction on how to provide the resident with activity, with their limitations and the suggested frequency in which the resident is offered the activities according to their activity plan. 2. The Administrator and Activity Director will ensure ongoing compliance, following the required OARs, for the activity assessment and activity plan requirements. The pre-admit, admission, and ongoing evaluation forms have been cross-referenced and the root cause for incomplete data collection was identified. 3. The Activity Director will routinely audit and the Administrator will spot audit on a monthly basis. 4. The Activity Director and Administrator will maintain ongoing compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impact the resident and others in the community are evaluated and included on the service or care plan, for 1 of 3 sampled residents (#1) who had challenging behaviors in the MCC. Findings include, but are not limited to: Resident 1 was admitted to the MCC in 10/2022 with diagnoses including vascular dementia with behavioral disturbance. The current "Evaluation and Service Plan" document, dated 02/09/23, indicated the resident was "verbally aggressive or abusive, demanding, uncooperative or disruptive" and the behavior required a "Behavior Plan." In an interview on 04/05/23, Staff 9 (Direct Care) reported Resident 1's most challenging behaviors were: * Screaming, because it triggered other residents on the unit; * Trying to stand up from the recliner in the common living room area because s/he might fall; * Hitting staff when they were assisting with ADLs; and * Throwing peers' plates and drinks on the floor during mealtimes. The record indicated multiple incidents between 01/29/23 and the date of the survey of Resident 1 having falls, physical altercations with peers, and resisting care from staff. During the survey, the resident was observed on multiple occasions yelling/screaming and trying to stand up from his/her chair. Resident 1's behavior plan, called the "Personalized Expression Plan," identified becoming "physically and verbally aggressive with staff" and becoming "agitated and not wanting to sit still [up and down]" as behaviors of concern. There were eight interventions for staff to consider for responding to behaviors, but the plan did not indicate for which behavior the various interventions should be attempted. Staff 9 reported talking about chickens or showing him/her a video about chickens was effective in calming Resident 1 down - this intervention was not on the behavior plan. Further, the behavior plan did not address Resident 1's screaming and throwing plates and drinks on the floor. Resident 1's behaviors and behavior plan was reviewed with Staff 1 (ALF Administrator), Staff 2 (RN) and Staff 3 (LPN) on 04/07/23. They explained they viewed the behavior plan as a fluid document which changed often, but acknowledged not all Resident 1's challenging behaviors were addressed on the plan.

Z 165 - OAR 411-057-0160(e) Behavior 1. The leadership team has reviewed the OARs for behavior planning and cross referenced the internal tools to ensure all OARs are captured on the internal systems, processes, policies, procedures, and protocols were reviewed by the leadership team to ensure ongoing compliance. Resident 1's personal expression plan aka behavior plan was reviewed by a work group including nursing, resident care coordinators, wellness techs, and direct care staff to separate the behaviors and match the interventions accordingly. Interventions were added based on direct care staff input. Care staff will be involved moving forward monthly in the monthly house meeting to contribute in the development of the behaviors of all the residents in the home. 2. The leadership team has developed a Behavior Plan (Personal Expression Plan) work group including but not limited to nursing, resident care coordinators, wellness techs and direct care staff to approach training in the moment on the floor as well as meeting twice weekly to review and update PEP's for all residents.    3. Resident Care Coordinators will ensure Behavior plan/PEP training is on peer training checklist and include ongoing training, adding the PEPs reviews to the small monthly house meetings to seek feedback on the baseline expressions and effectiveness of the interventions and staff documentation and for the care team to encourage comments/notes in comments section of Service Plan to gather observations and input.   4. The RCC's, LPN, and RN will be responsible for upholding ongoing compliance.

The findings of the re-licensure survey conducted 04/04/23 through 04/07/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second revisit to the re-licensure survey of  0407/23, conducted from 08/07/23 through 08/09/23, are documented in this report. It was determined the facility was in substantial compliance with OARS 411 Division 54 for Residential Care and Assisted Living Facilities, OARS 411 Division 57 for Memory Care Communities and OARS 411 Division 004 for Home and Community Based Regulations.

Based on observation, record review and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 07/06/22 revealed: * Splatters, spills, and drips noted on: - Food storage bins under the tray-line; - Exterior of the range; - Interior of the microwave; * Black matter noted on the can opener blade; * Dust and debris was built up on metal storage shelves throughout the kitchen; * Dust and debris noted on cage of two rotating fans blowing onto the tray line and into the dish washing area; * Two bottles of opened mustard noted to require refrigeration were left in an un-refrigerated food storage area; * Undated food items and food items with dates older than seven days were noted in the reach in refrigerator; * The cove-base flooring was damaged in corners creating an un-cleanable surface; and * The back entrance to the kitchen was left open allowing the entrance of flies and pests. The commercial high temperature dish machine was observed in operation three times. It was not reaching the specified temperature required for the sanitizing rinse cycle. Observations of the Tuscany House kitchen and food storage areas on 07/06/22 revealed: * Spills, splatters, and debris noted in drawers and on shelves; * Splatters noted on the interior of the microwave; * Garbage can lacked a lid; * Damage to entry door frame by the refrigerator seating area island around kitchen; * No documented evidence the temperatures of the dish sanitizer or the refrigerator were being monitored; and * Food dated past seven days noted in refrigerator. Observations of the Ranch House kitchen and food storage areas on 07/06/22 revealed: * Spills, splatters, and debris noted in drawers and on shelves; * Garbage can lacked a lid; * Damage to seating area island around kitchen; and * No documented evidence the temperatures of the dish sanitizer or the refrigerator were being monitored. The kitchens were toured with Staff 1 (Administrator) and Staff 2 (Dietary Manager). Disposable dishes were in use. The areas in need of cleaning and repair were reviewed with Staff 1 and Staff 2. They acknowledged the findings.

***Commercial Kitchen This Rule is not met as evidenced by: Based on observation, record review and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation 1. Splatters, spills, and drips noted on: - Food storage bins under the tray-line; - Exterior of the range; - Interior of the microwave;   Actions: All of the Splatters, spills and drips were cleaned the day of the inspection. System Correction: On going cleaning has been added to the daily cleaning task list to be completed by kitchen staff by the end of the day and as needed during the day as spills occur. Audit/Follow up/Responsible Party: The dietary manager and assistant manager will inspect all areas daily Monday - Saturday for compliance. 2. Black Matter noted on the can opener blade.   Actions: The can opener was taken apart, cleaned and sanitized. The cleaning of the can opener was put on a daily and as needed sanitizing list. System Correction: The on going cleaning has been added to the daily cleaning/sanitizing task list to be completed by kitchen staff by the end of the day and as needed during the day as needed. It is also taken apart, cleaned and sanitized after the dinner prep has occurred. Audit/Follow up/Responsible Party: The dietary manager and assistant manager will inspect the can opener daily Monday - Saturday for compliance. 3. Dust and debris was built up on metal storage shelves throughout the kitchen; Action: The metal shelves throughout the kitchen were cleaned the day of the inspection. System Correction: The on going cleaning of the shelves was put on the weekly cleaning task list to be completed by the kitchen staff on Fridays. Audit/Follow Up/ Responsible Party: Dietary management will inspect weekly that the cleaning has been done. 4. Dust and debris noted on cage of two rotating fans blowing onto the tray line and into the dish washing area; Action: The fans were taken apart and cleaned the day of the inspection. System Correction: The on going cleaning of the fans will be put on the weekly cleaning task list to be completed by the kitchen staff on Fridays. Audit/Follow Up/ Responsible Party: Dietary management will inspect weekly that the cleaning has been done. 5. Two bottles of opened mustard noted to require refrigeration were left in an un-refrigerated food storage area; Action: The mustard was discarded immediately. All Staff will be in-serviced on food safety with a focus on refrigeration, dating food items, and discarding items that are out of compliance. System Correction: Daily checks have been added to the task list for the kitchen staff to be checking every kitchen for un-refrigerated food that requires refrigeration, Out dated food, and un-dated food items. Audit/Follow Up/ Responsible Party: Dietary management will do ongoing monitoring of the kitchen areas for any violations. 6. Un-dated food items and food items with dates older than seven days were noted in the reach in refrigerator; Action: Out dated food and un-dated food were discarded immediately during inspection. All Staff will be in-serviced on food safety with a focus on refrigeration, dating food items, and discarding items that are out of compliance. System Correction: Daily checks have been added to the task list for the kitchen staff to be checking every kitchen for food that requires refrigeration, out dated food, and un-dated food items. Audit/Follow Up/ Responsible Party: Dietary management will do ongoing monitoring of the kitchen compliance. 7. The cove-base flooring was damaged in corners creating an un-cleanable surface; and Action: Maintenance inspected the areas noted and we determined that a full replacement of the Rose Arbor kitchen flooring would be required to bring the condition back in compliance. A request for bids was made on 7/6/2022. As of 7/19/2022 they have yet to come in to the facility. System Correction: Flooring will be monitored daily by kitchen management to note condition changes after the new floor has been installed. Any noted damage or areas of disrepair will be reported to the Administrator and the maintenance director immediately and submitted for repair. Audit/Follow Up/ Responsible Party: Dietary management will do ongoing monitoring of flooring. 8. The back entrance to the kitchen was left open allowing the entrance of flies and pests. Action: The back door was immediately closed and not proped open until a screen door could be installed. A screen door was purchased and it was installed on 7/19/2022. Staff were in-serviced on the importance of closing the door to avoid pests and bugs to enter the kitchen. When the staff needs to prop the door open the screen must be in place. System Correction: Kitchen staff and dietary management is responsible for monitoring and ensuring that the screen is in place during times that the door is proped open. Audit/Follow Up/ Responsible Party: Dietary management will do a weekly and as needed check on the screen for damage and replace as needed. 9. The commercial high temperature dish machine was observed in operation three times. It was not reaching the specified temperature required for the sanitizing rinse cycle. Action: The use of the commercial dish machine was discontinued until it could be inspected and repaired by our vendor. The three sink sanitizing system was started and will continue until the dish machine comes up to temp. System Correction: A tempature will be taken twice daily (morning and evening) by kitchen staff and recorded in their temp log. Kitchen staff in-serviced on the required tempature and what to do in the event that the dish washer is not reaching the required temp. Audit/Follow Up/ Responsible Party: Dietary management will audit the temp logs daily. *** Observations of the Tuscany House kitchen and food storage areas on 07/06/22 revealed: 1. * Spills, splatters, and debris noted in drawers and on shelves; * Splatters noted on the interior of the microwave; Actions: All of the Splatters, spills and debris on and in the drawers and on shelves were cleaned the day of the inspection. Action: All cleaning was completed by the end of the work day on 7/6/2022. System Correction: On going cleaning has been added to the Night shift care staff's cleaning task list to be completed as needed throughout the day, by caregivers and dietary staff. Audit/Follow up/Responsible Party: The dietary manager and assistant manager will inspect all areas daily Monday - Saturday for compliance. Reporting any deficency to the Resident Care Coordinator for staff intervention, training, and educational support. 2. Garbage can lacked a lid; Action: Commercial garbage cans were ordered and received with foot operated lids for both memory care homes. System Correction: Kitchen staff will do daily checks for lids, or damage and report any findings to the dietary management.   Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. Any damage noted or replacement needed will be reported to the Administrator. 3. Damage to entry door frame by the refrigerator seating area island around kitchen; Action: The administrator and the maintenance director met and reviewed the repairs that would be required. A plan was put in motion with the highest priority. System Correction:  Dietary management will note any damage in their daily audit of the kitchens and report to the Administrator and Maintenance director. Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. Any damage noted or replacement needed will be reported to the Administrator. 4. No documented evidence the temperatures of the dish sanitizer or the refrigerator were being monitored; Action: Dietary management created a temp log for each house and care staff training was completed. System Correction: Care staff in the memory care homes are now responsible for completing a temp check on the refidgerator, freezer and sanitizer twice daily, at breakfast and dinner, and logging it in the temp log binder in each home. Staff has been in-serviced on their responsibility, temp requirements and who to report to when the temps are out of range. Staff will have continued education during food safety in-services.    Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. non compliance will be reported to the Administrator for additional education and or corrective action. The regional Dietitcian will also complete routine spot checks, and complete monthly continued education with the dietary, leadership, and direct care staff on food safety, survey preparedness, system auditing, and competency compliance. 5. Food dated past seven days noted in refrigerator. Action: Any food that was beyond the 7 days or unlabeled was discarded immediately. System Correction: Care staff are responsible for checking the dates on items or discarding items as they use them.   Kitchen Staff will check daily while in the homes serving meals for dated or unlabled food to make sure that there is nothing out of range. Regular food safety education will be included in the in-service schedule. Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. Non compliance will be reported to the Administrator for additional education and or corrective action.   ***Observations of the Ranch House kitchen and food storage areas on 07/06/22 revealed: 1. Spills, splatters, and debris noted in drawers and on shelves; * Splatters noted on the interior of the microwave; Actions: All of the Splatters, spills and debris on and in the drawers and on shelves were cleaned the day of the inspection. Action: All cleaning was completed by the end of the work day on 7/6/2022. System Correction: On going cleaning has been added to the Night shift care staff's cleaning task list and will be done as needed througout the day by dietary and direct care staff. Audit/Follow up/Responsible Party: The dietary manager and assistant manager will inspect all areas daily Monday - Saturday for compliance. Reporting any deficency to the Resident Care Coordinator for intervention, training and educational support. 2. Garbage can lacked a lid; Action: Commercial garbage cans were ordered and received with foot operated lids for both memory care homes. System Correction: Kitchen staff will do daily checks for lids, or damage and report any findings to the dietary management.   Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. Any damage noted or replacement needed will be reported to the Administrator. 3. Damage to entry door frame by the refrigerator seating area island around kitchen; Action: The administrator and the maintenance director met and reviewed the repairs that would be required. A plan was put in motion with the highest priority. System Correction:  Dietary management will note any damage in their daily audit of the kitchens and report to the Administrator and Maintenance director. Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. Any damage noted or replacement needed will be reported to the Administrator.   4. No documented evidence the temperatures of the dish sanitizer or the refrigerator were being monitored; and Action: Dietary management created a temp log for each house and care staff training was completed. System Correction: Care staff in the memory care homes are now responsible for completing a temp check on the refigerator, freezer and sanitizer twice daily, at breakfast and dinner, and logging it in the temp log binder in each home. Staff has been in-serviced on their responsibility, temp requirements and who to report to when the temps are out of range. Staff will have continued education during food safety in-services.    Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. non compliance will be reported to the Administrator for additional education and or corrective action.

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 C240.

The findings of the kitchen inspection, conducted 07/05/22, 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 07/06/22, conducted 10/04/22, 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.