Guardian Angel Homes Memory Care

Residential Care Facility
540 NW 12TH ST, HERMISTON, OR 97838

Facility Information

Facility ID 50M428
Status Active
County Umatilla
Licensed Beds 32
Phone 5415649070
Email [email protected]
Administrator JENNIFER CICERO
Active Date Apr 25, 2016
Owner Hermiston Healthcare, LLC
307 N. LINCOLN STREET, STE A
POST FALLS 83854
Funding Medicaid
Services:

No special services listed

5
Total Surveys
15
Total Deficiencies
0
Abuse Violations
10
Licensing Violations
0
Notices

Violations

Licensing: 00406281-AP-357302
Licensing: 00402694-AP-353609
Licensing: 00401534-AP-352428
Licensing: 00355860-AP-306198
Licensing: 00346207-AP-296647
Licensing: 00301460-AP-254647
Licensing: OR0004578801
Licensing: 00259596-AP-214797
Licensing: 00256556-AP-211999
Licensing: OR0003959900

Survey History

Survey YBER

1 Deficiencies
Date: 7/17/2025
Type: Complaint Investig., Licensure Complaint

Citations: 1

Citation #1: C0361 - Acuity-Based Staffing Tool

Visit History:
1 Visit: 7/17/2025 | Not Corrected
Inspection Findings:
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.

Survey KIT001087

3 Deficiencies
Date: 11/4/2024
Type: Kitchen

Citations: 3

Citation #1: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:
t Visit: 11/4/2024 | Not Corrected
1 Visit: 3/13/2025 | Not Corrected
2 Visit: 6/4/2025 | Not Corrected
3 Visit: 7/28/2025 | Not Corrected
Regulation:
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).
Inspection Findings:
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.

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).

This Rule is not met as evidenced by:
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.

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).

This Rule is not met as evidenced by:
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.

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).

This Rule is not met as evidenced by:
Plan of Correction:
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.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.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.

Citation #2: C0455 - Inspections and Investigation: Insp Interval

Visit History:
1 Visit: 3/13/2025 | Not Corrected
2 Visit: 6/4/2025 | Not Corrected
3 Visit: 7/28/2025 | Not Corrected
Regulation:
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.
Inspection Findings:
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.

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.

This Rule is not met as evidenced by:

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.

This Rule is not met as evidenced by:
Plan of Correction:
See C240see C 240

Citation #3: Z0142 - Administration Compliance

Visit History:
t Visit: 11/4/2024 | Not Corrected
1 Visit: 3/13/2025 | Not Corrected
2 Visit: 6/4/2025 | Not Corrected
3 Visit: 7/28/2025 | Not Corrected
Regulation:
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.
Inspection Findings:
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.

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.

This Rule is not met as evidenced by:
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

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.

This Rule is not met as evidenced by:

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.

This Rule is not met as evidenced by:
Plan of Correction:
Refer to C240.See C240see C 240

Survey H1EC

0 Deficiencies
Date: 8/7/2023
Type: State Licensure, Other

Citations: 1

Citation #1: C0000 - Comment

Visit History:
1 Visit: 8/9/2023 | Not Corrected
Inspection Findings:
The findings of the kitchen inspection, conducted from 08/07/23 through 08/09/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Survey VFYY

9 Deficiencies
Date: 4/4/2023
Type: Validation, Re-Licensure

Citations: 10

Citation #1: C0000 - Comment

Visit History:
1 Visit: 4/7/2023 | Not Corrected
2 Visit: 8/9/2023 | Not Corrected
Inspection Findings:
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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: 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.

Citation #2: C0252 - Resident Move-In and Eval: Res Evaluation

Visit History:
1 Visit: 4/7/2023 | Not Corrected
2 Visit: 8/9/2023 | Corrected: 6/5/2023
Inspection Findings:
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.
Plan of Correction:
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.

Citation #3: C0270 - Change of Condition and Monitoring

Visit History:
1 Visit: 4/7/2023 | Not Corrected
2 Visit: 8/9/2023 | Corrected: 6/5/2023
Inspection Findings:
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.
Plan of Correction:
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.

Citation #4: C0420 - Fire and Life Safety: Safety

Visit History:
1 Visit: 4/7/2023 | Not Corrected
2 Visit: 8/9/2023 | Corrected: 6/5/2023
Inspection Findings:
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.
Plan of Correction:
C 420 OAR 411-054-0090 Fire and Life Safety: Safety1. 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.

Citation #5: C0422 - Fire and Life Safety: Training For Residents

Visit History:
1 Visit: 4/7/2023 | Not Corrected
2 Visit: 8/9/2023 | Corrected: 6/5/2023
Inspection Findings:
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.
Plan of Correction:
C 422 OAR 411-054-0090 (5) Fire and Life safety: Training for Residents1.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.

Citation #6: C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable

Visit History:
1 Visit: 4/7/2023 | Not Corrected
2 Visit: 8/9/2023 | Corrected: 6/5/2023
Inspection Findings:
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.
Plan of Correction:
C 555 OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, Cable1.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.

Citation #7: Z0142 - Administration Compliance

Visit History:
1 Visit: 4/7/2023 | Not Corrected
2 Visit: 8/9/2023 | Corrected: 6/5/2023
Inspection Findings:
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.
Plan of Correction:
Please refer to the POC for citation C 420, C 422 and C 555

Citation #8: Z0162 - Compliance With Rules Health Care

Visit History:
1 Visit: 4/7/2023 | Not Corrected
2 Visit: 8/9/2023 | Corrected: 6/5/2023
Inspection Findings:
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.
Plan of Correction:
Please refer to the POC for citation C 252 and C 270

Citation #9: Z0164 - Activities

Visit History:
1 Visit: 4/7/2023 | Not Corrected
2 Visit: 8/9/2023 | Corrected: 6/5/2023
Inspection Findings:
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.
Plan of Correction:
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.

Citation #10: Z0165 - Behavior

Visit History:
1 Visit: 4/7/2023 | Not Corrected
2 Visit: 8/9/2023 | Corrected: 6/5/2023
Inspection Findings:
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.
Plan of Correction:
Z 165 - OAR 411-057-0160(e) Behavior1. 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.

Survey OEX0

2 Deficiencies
Date: 7/6/2022
Type: State Licensure, Other

Citations: 3

Citation #1: C0000 - Comment

Visit History:
1 Visit: 7/6/2022 | Not Corrected
2 Visit: 10/4/2022 | Not Corrected
Inspection Findings:
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.

Citation #2: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:
1 Visit: 7/6/2022 | Not Corrected
2 Visit: 10/4/2022 | Corrected: 9/6/2022
Inspection Findings:
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.
Plan of Correction:
***Commercial KitchenThis 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.

Citation #3: Z0142 - Administration Compliance

Visit History:
1 Visit: 7/6/2022 | Not Corrected
2 Visit: 10/4/2022 | Corrected: 9/6/2022
Inspection Findings:
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.

Data sourced from Oregon Long-Term Care Licensing

Report generated: 2025-12-12T14:45:15.108Z