Friendsview Retirement Community

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 4 of 6 sampled residents (#s 2, 5, 6, and 7) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 08/2025 with diagnoses including dementia with agitation. The resident’s 05/01/26 through 06/01/26 MARs and current physician orders were reviewed, and the following was identified: * Four of six standing bowel care orders were not listed on the resident’s MAR; and * On 05/22/26, 05/23/25, and 05/29/26 the evening shift MT noted the resident’s quetiapine (for dementia with severe agitation) was “not available,” although the resident was administered the medication on the morning shift each day of the month and on the evening shift on 05/24/26 through 05/28/26. In an interview on 06/03/26 at 9:23 am, Staff 10 (MT) stated she was unsure why the medication would be unavailable on those dates. Staff 4 (LPN), on 06/03/26 at 9:38 am, indicated she would have expected the MT to speak with day shift MTs about the medication that was unavailable or to re-order it from the pharmacy. The need to ensure the MAR was accurate was discussed with Staff 1 (Administrator) on 06/03/26 at 12:00 pm. She acknowledged the findings. 2. Resident 2 was admitted to the facility in 05/2025 with diagnoses including bed confinement status and Alzheimer’s disease. Resident 2's MARs from 05/01/26 through 06/01/26 and physician orders were reviewed. a. The following PRN medications lacked instructions for sequential order of use: * Morphine 20mg/ml (for pain, difficulty breathing); and * Lorazepam 0.5mg (for anxiety, difficulty breathing, or end of life); b. The following PRN medications lacked resident-specific parameters for use: * Lorazepam 0.5mg (for anxiety, difficulty breathing, or end of life); * Haloperidol actate 2mg/ml (for hallucinations, agitation, nausea, vomiting); and * Risperidone 0.25mg (for behavioral disorders associated with dementia). The need to ensure MARs were accurate and provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (Administrator) and Staff 2 (Director of Nursing/RN) on 06/03/26 at 1:22 pm. They acknowledged the findings. 3. Resident 7 was admitted to the facility in 05/2025 with diagnoses including acute kidney failure, pancreatitis, and diabetes mellitus Type II. The resident’s 05/01/26 through 06/01/26 MARs and current physician orders were reviewed, and the following was identified: The following PRN medications lacked clear instructions for sequential order of use: · Milk of magnesia (for constipation); · Dulcolax suppository 10 mg bisacodyl (for constipation); · Polyethylene glycol 3350 Oral Packet (for constipation); · Polyethylene glycol 3350 powder bulk (for constipation); · Imodium AD tablet 2 mg give 2 tablets (for diarrhea); and · Imodium AD tablet 2mg give 1 tablet (for diarrhea). b. The following PRN medications lacked reason for use and resident-specific parameters: • Lactulose Oral Solution 10/15ml give 30 ml (synthetic sugar). The need to ensure MARs were accurate and provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 2 (Director of Nursing/RN) on 06/02/23 at 4:15 pm, and with Staff 1 (Administrator) on 06/03/26 at 12:30 pm. They acknowledged the findings. 4. Resident 6 moved into the facility in 09/2025 with diagnoses including diabetes mellitus. The resident’s MAR dated 05/01/26 to 05/30/26, and physician’s orders dated 04/09/26, were reviewed, and the following was noted: *Orders for clobetasol propionate external liquid 0.05% (a topical steroid used to treat severe skin conditions) as needed, lacked a reason for use. *Orders to place mineral oil in the ears for three days if wax required softening before irrigation lacked instructions on the dosage to be used. In an interview on 06/02/26 at 11:10 am with Staff 8 (RCC), she confirmed the electronic MAR system lacked a reason for use and dosage for the PRN medications. The need to ensure residents' MARs were accurate and included resident-specific instructions for administration of PRN medications was discussed on 06/03/26 at approximately 12:45 pm with Staff 1(Administrator) and Staff 2 (Director of Nursing/RN). They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? The Director of Nursing will complete a 100% audit of all current bowel care orders and PRN medication orders to ensure orders are accurate and complete. The audit will verify that duplicate orders are discontinued, standing bowel care orders are reinstated after SNF stays when applicable, and all PRN orders include a clear reason for use, dose, frequency, sequence of use when applicable, and resident-specific administration parameters. Prescribing practitioners will be contacted immediately for clarification of incomplete orders. Medication records will be updated after clarified orders are received. Medication Technicians will receive education regarding when medication refills must be requested and the required process when medications are not received or when prescribers/pharmacies do not respond to refill requests. 2. How will the system be corrected so this violation will not happen again? The facility will revise the medication order review process to require nursing review of all new and revised PRN medication orders prior to activation on the MAR. PRN medication orders must include clinical indication, resident-specific parameters, dose, frequency, and sequence of use when more than one PRN medication is available for the same condition. The facility will also revise the medication refill process to require Medication Technicians to mark medication cards seven days before the medication is expected to run out and document the refill request date. Any medication not received three days before running out will be escalated to the charge nurse, Resident Care Manager, or Director of Nursing for urgent follow-up with the pharmacy or prescribing practitioner. 3. How often will the area needing correction be evaluated? The Director of Nursing or designee will audit 100% of new PRN medication orders weekly and complete weekly medication cart audits to verify medications are reordered, received, and available for administration. Audits will continue weekly for eight weeks, then monthly through the QAPI process. Any deficiencies identified will be corrected immediately, with additional staff coaching or education provided as needed. 4. Who will be responsible to see that the corrections are completed/monitored? Director of Nursing or designee.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission for 1 of 1 sampled resident (#1), and to ensure all residents were re-instructed at least annually. Findings include, but are not limited to: Fire and life safety records were requested and reviewed on 06/02/26 and 06/03/25, and the following was identified: * There was no documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission for Resident (#1); and * There was no documented evidence of fire and life safety training provided to residents at least annually. The need to ensure residents received fire and life safety training within 24 hours of admission and at least annually was discussed with Staff 1 (Administrator) on 06/03/26 at 9:30 am. She reported there had been no resident instruction on fire and life safety within 24 hours of admission or annually.

All current residents will have documented fire and life safety education regarding emergency procedures, evacuation routes, designated meeting locations, and staff responsibilities during an emergency. Resident records will be reviewed to ensure documentation of resident fire safety education is complete. Any missing documentation will be completed immediately. 2. How will the system be corrected so this violation will not happen again? Fire and life safety education will incorporated into the admission process and annual resident review. A standardized documentation form will be implemented to ensure completion and verification of resident education. The admission checklist will require completion of resident fire safety education before the admission process is finalized. 3. How often will the area needing correction be evaluated? Weekly for eight weeks, then monthly through the Quality Assurance Performance Improvement (QAPI) program. 4. Who will be responsible? Administrator or designee.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

Based on observation and interview, it was determined the facility failed to provide individual privacy in their own unit for multiple unsampled residents. Findings include, but are not limited to: During the survey of 06/01/26 through 06/03/26, units 60, 62, 69, and 70 on the Garden View MCC were observed to have two residents sharing each unit and bathroom. The bathrooms had a curtain instead of a door and did not have a way to lock for privacy. In a tour with Staff 1 (Administrator) on 06/03/26 at 10:00 am, it was confirmed the shared units did not have a lockable bathroom door. Staff 1 acknowledged the inability to lock bathroom doors in a shared unit with two residents limited their privacy. The need to ensure residents were provided with individual privacy in their own unit was discussed with Staff 1 on 06/03/26 at 12:30 pm. She acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? Upon identification of the deficiency, lockable bathroom door hardware was installed on the two occupied shared resident bathrooms in the Gardenview Memory Care neighborhood. Installation of lockable door hardware for the remaining two shared resident bathrooms has been scheduled and will be completed prior to the facility's alleged compliance date. All shared resident bathrooms will provide residents with the ability to secure privacy while using the bathroom. 2. How will the system be corrected so this violation will not happen again? The facility has revised its environmental compliance rounds to include verification that resident bathroom doors in shared accommodations meet Oregon regulatory requirements for privacy. Facility leadership will review all future renovation and maintenance projects to ensure resident privacy requirements are maintained and any deficiencies are corrected promptly. 3. How often will the area needing correction be evaluated? The Administrator or designee will verify completion of the remaining door installations and will include resident privacy features as part of the monthly environmental and life safety rounds. Findings will be reviewed through the facility's Quality Assurance Performance Improvement (QAPI) program. 4. Who will be responsible to see that the corrections are completed/monitored? Administrator and Facilities Director (or designee).

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 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 C422.

See C422 All current residents will have documented fire and life safety education regarding emergency procedures, evacuation routes, designated meeting locations, and staff responsibilities during an emergency. Resident records will be reviewed to ensure documentation of resident fire safety education is complete. Any missing documentation will be completed immediately. 2. How will the system be corrected so this violation will not happen again? Fire and life safety education will incorporated into the admission process and annual resident review. A standardized documentation form will be implemented to ensure completion and verification of resident education. The admission checklist will require completion of resident fire safety education before the admission process is finalized. 3. How often will the area needing correction be evaluated? Weekly for eight weeks, then monthly through the Quality Assurance Performance Improvement (QAPI) program. 4. Who will be responsible? Administrator or designee.

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

Based on interview and record review, it was determined the facility failed to ensure all non-direct care staff completed pre-service dementia training for 1 of 1 staff (#15) whose pre-service training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 06/02/26, and the following was identified: Staff 15 (Wait Staff) was hired on 03/09/26. There was no documented evidence Staff 15 completed pre-service dementia training. On 06/02/26 at approximately 2:00 pm, Staff 1 (Administrator) indicated that non-direct care staff were not required to complete pre-service dementia training. On 06/03/26 at 12:00 pm, the need for all non-direct care staff to complete the required pre-service dementia training because the MCC and the RCF were under the same license was discussed with Staff 1. She acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? Upon identification of the deficiency, Human Resources conducted a comprehensive audit of all Memory Care and healthcare staff training records. The audit confirmed that applicable staff had completed or were in compliance with the required dementia education; however, the required preservice dementia course had not been assigned to all staff as required. Human Resources immediately assigned the preservice dementia course to all applicable staff and verified that all required dementia training assignments were complete and documented. 2. How will the system be corrected so this violation will not happen again? The facility revised its onboarding and training assignment process to ensure all staff required to receive dementia training are assigned the preservice dementia course at hire and prior to working independently with Memory Care residents. Human Resources will utilize a standardized onboarding checklist and monthly training report to verify all required dementia education has been assigned and completed within regulatory timeframes. Any discrepancies identified will be corrected immediately. 3. How often will the area needing correction be evaluated? Human Resources will audit dementia training assignments monthly for six months and report findings to the Administrator and Director of Nursing through the Quality Assurance Performance Improvement (QAPI) program. Corrective action will be implemented immediately if any missing assignments are identified. 4. Who will be responsible to see that the corrections are completed/monitored? Human Resources Director, in collaboration with the Director of Nursing.

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 C310.

See C310 1. What actions will be taken to correct the rule violation for each example/resident? The Director of Nursing will complete a 100% audit of all current bowel care orders and PRN medication orders to ensure orders are accurate and complete. The audit will verify that duplicate orders are discontinued, standing bowel care orders are reinstated after SNF stays when applicable, and all PRN orders include a clear reason for use, dose, frequency, sequence of use when applicable, and resident-specific administration parameters. Prescribing practitioners will be contacted immediately for clarification of incomplete orders. Medication records will be updated after clarified orders are received. Medication Technicians will receive education regarding when medication refills must be requested and the required process when medications are not received or when prescribers/pharmacies do not respond to refill requests. 2. How will the system be corrected so this violation will not happen again? The facility will revise the medication order review process to require nursing review of all new and revised PRN medication orders prior to activation on the MAR. PRN medication orders must include clinical indication, resident-specific parameters, dose, frequency, and sequence of use when more than one PRN medication is available for the same condition. The facility will also revise the medication refill process to require Medication Technicians to mark medication cards seven days before the medication is expected to run out and document the refill request date. Any medication not received three days before running out will be escalated to the charge nurse, Resident Care Manager, or Director of Nursing for urgent follow-up with the pharmacy or prescribing practitioner. 3. How often will the area needing correction be evaluated? The Director of Nursing or designee will audit 100% of new PRN medication orders weekly and complete weekly medication cart audits to verify medications are reordered, received, and available for administration. Audits will continue weekly for eight weeks, then monthly through the QAPI process. Any deficiencies identified will be corrected immediately, with additional staff coaching or education provided as needed. 4. Who will be responsible to see that the corrections are completed/monitored? Director of Nursing or designee.

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 the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations of the facility’s two food preparation kitchen areas, 4 meal service areas and two dry food storage areas occurred on 11/19/25 at 10:20 am through 3:15 pm and revealed the following areas: 1. Charles Reeds Plaza kitchen (Floor 4) a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease was visible on or underneath the following: * Hot pads/mitts; * Interior of ovens; * Exterior of Turbo Chef Oven; * Industrial can opener and housing; and * Interior of plastic bin storing cooking utensils. b. The following areas were found in need of repair: * Multiple cutting boards heavily scored and stained; * Sauté pans scored/scraped with non-stick coating damaged; and * Multiple hot pads/mitts, torn or with holes. c. Multiple potentially hazardous food items were found stored in the refrigerator without dates opened or prepared. Multiple food items found not covered/protected from potential contamination while stored. d. Multiple dishwashing racks were observed stored on the floor. e. Multiple kitchen staff were observed to prepare foods or handle clean equipment without effective hair restraints. f. Containers of bulk dry food items observed with scoops stored inside the bins with the handles touching the food products potentially contaminating the food products. 2. Charles Reeds Plaza Kitchenette/food service (Floor 2) a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease was visible on or underneath the following: * Black matt in front of dish machine; * Area under the black matt by dish machine; and * Knife holder and knives. b. The following areas were found in need of repair: * Walls behind dish machine with water damage. c. Plastic hose from dish machine observed stuck into floor sink drain touching the bottom of the drain. No air gap was identified to prevent potential back flow. Plastic piping touching bottom of drain that was not clean. Staff 2 (Dining Services Director) acknowledged the plastic pipe should not be resting in the bottom of the drain. d. Multiple dishwashing racks were observed stored on the floor. e. Multiple small plastic service bowls were observed with worn glaze, heavily scored and pitted needing replacement. 3. Garden view memory care kitchen a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease was visible on or underneath the following: * Floors and walls under dish machine area; * Caulking behind hand wash sink at entry; * Interior of drawers holding utensils; * Interior of floor drain under sink in service area; and * Industrial can opener and housing. Staff 3 (Chef) toured areas with surveyors and acknowledged the above items needing addressed. 4. RCC main kitchen and dining area: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease was visible on or underneath the following: * Kitchen entry threshold corners/edges; * Flooring and wall under/around dishwasher; * Hot pads/mitts; * Interior of regular and convection ovens; * Floors under ovens; * Walls behind oven and grill; * Interior of hot food transport boxes; * Interior of drawers; * Sides of fryer, stove, oven; * Metal racks storing clean dishes; * Industrial can openers and housings; * Industrial slicer; * Walls and floors behind/under steam jacket kettle and tilt skillet; * Floor drains throughout kitchen; * Walk in cooler flooring in corners/edges under racks; * Walk in cooler stationary racks; * Movable baker/speed racks in walk in cooler; * Sprinkler head and ceiling in walk in cooler; and * Interior of ice machine. b. The following areas were found in need of repair: * Multiple cutting boards heavily scored and/or stained; * Sauté pans scored/scraped with non-stick coating damaged; * Oven mitts damaged/worn/holes; * Large gap in ceiling tile where electrical conduit enters/exits kitchen; * Cracked/missing cove base tile threshold entry way to kitchen; * Missing caulking/seal in freezer holding ice cream. Same freezer with large amount of frost/ice build up. c. Hot temperature dish machine was not registering proper sanitizing temperatures. Multiple cycles were run without rinse temperature reaching above 160 degrees. Staff 4 (Sous Chef) was interviewed and stated that he belived the temperature should be 160 degrees. Proper sanitizing temperatures for hot temp machines should reach 180 degrees. Records were reviewed and multiple entries were observed under 180 degrees. Staff 2 was interviewed and confirmed the temperature of the dish machine should be reaching 180 degrees for effective sanitizing. Facility was not sure how long the dish machine was not effectively sanitizing dishes. Facility ensured the dishes would be sanitized using three compartment chemical sanitizing until the dish machine could be fixed. d. Multiple dishwashing racks were observed stored on the floor. e. Multiple kitchen staff were observed to prepare foods or handle clean equipment without effective hair restraints. f. Multiple ice cream bars and/or sandwiches were found stored in a freezer that were soft and not frozen. Staff 2 stated no items should have been stored in that freezer as it was not freezing properly. Staff 2 indicated those items would be discarded. g. Slicer was noted to be stored uncovered and exposed to potential contamination. h. Multiple oven racks observed stored on the floor next to the convection ovens. i. Multiple green metal racks noted with yellow tape along the edges. The tape was worn, pealed, and frayed in multiple areas. Multiple areas leaving a sticky residue behind. This yielded a non-smooth surface. j. Salad bar area was observed during lunch service. A staff member was observed to replenish salad area and was handling Ready to Eat lettuce/spinach bare hands. That staff member had longer painted nails. Staff 2 acknowledged the staff member should have been waring gloves and directed the staff member to wear gloves. 4. RCC main dry storage area a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease was visible on or underneath the following: * Floors in the corners/edges and under metal racks; * Metal cart; and * Metal food storage racks. b. The following areas were found in need of repair: * Light switch and electrical outlet with missing or damaged outlet cover. c. Multiple metal racks observed with yellow tape. Tape was worn, ripped, frayed in areas yielding a non-smooth surface. Where tape had pulled away or worn left a sticky residue. 4. RCC floor kitchenette a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease was visible on or underneath the following: * Floors under tables in the dining room; and * Chairs in the dining area dirty and/or stained. b. The following areas were found in need of repair: * Large hole found by piping of dish washer; * Multiple cabinets observed with porous wood exposed where protective coating had worn or pealed; and * Large section of countertop by stove area was found with porous wood exposed. c. Bulk coffee bin observed with scoop stored in bin with handle touching the food product potentially contaminating food. Staff 2 toured all kitchen areas with surveyors and acknowledged findings. Staff 3 toured areas 1, 2, and 3 with surveyors and acknowledged areas. Staff 4 toured RCC areas with surveyors and acknowledged findings. At approximately 3:00 pm, surveyor reviewed all findings with Staff 1 (Administrator) who acknowledged areas needing correction.

Corrective Action Taken for All Residents Affected AREAS AND EQUIPMENT CLEANING AND SANITATION All identified areas with food spills, debris, grease, dust, and black matter have been cleaned and sanitized as follows: 1. Charles Reeds Plaza – Kitchen (Floor 4) Accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease as identified in the statement of deficiencies has been cleaned and sanitized, including: • Hot pads/mitts • Interior of ovens • Exterior of Turbo Chef Oven • Industrial can opener and housing • Interior of plastic bin storing cooking utensils cleaned and utensils being stored out of bin. 2. Charles Beals (Reeds) Plaza – Kitchenette/Food Service (Floor 2): Accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease has been cleaned and sanitized, including: • Black mat in front of dish machine • Area under the black mat by dish machine • Knife holder and knives (knife holders were replaced) 3. Garden View Memory Care – Kitchen: Accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease has been cleaned and sanitized, including: • Floors and walls under dish machine area • Caulking behind hand wash sink at entry • Interior of drawers holding utensils • Interior of floor drain under sink in service area • Industrial can opener and housing 4. RCC Main Kitchen and Dining Area: Accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease has been cleaned and sanitized, including: • Kitchen entry threshold corners/edges • Flooring and wall under/around dishwasher • Hot pads/mitts • Interior of regular and convection ovens • Floors under ovens • Walls behind oven and grill • Interior of hot food transport boxes • Interior of drawers • Sides of fryer, stove, oven • Metal racks storing clean dishes • Industrial can openers and housings • Industrial slicer • Walls and floors behind/under steam jacket kettle and tilt skillet • Floor drains throughout kitchen • Walk-in cooler flooring in corners/edges under racks • Walk-in cooler stationary racks • Movable baker/speed racks in walk-in cooler • Sprinkler head and ceiling in walk-in cooler • Interior of ice machine 5. RCC Main Dry Storage Area: Accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease has been cleaned and sanitized, including: • Floors in corners/edges and under metal racks • Metal cart • Metal food storage racks RCC floor kitchenette: accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease on or underneath the following areas has been cleaned and sanitized: * Floors under tables in the dining room; and * Chairs in the dining area AREAS AND EQUIPMENT REPAIRS AND REPLACEMENT All areas identified in the statement of deficiencies have been repaired, replaced, or discarded as follows: 1. Charles Beals (Reeds) Plaza – Kitchen (Floor 4) • Cutting boards heavily scored and stained • Sauté pans scored/scraped with non-stick coating damaged • Multiple hot pads/mitts torn or with holes 2. Charles Beals (Reeds) Plaza – Kitchenette/Food Service (Floor 2) • Walls behind dish machine with water damage • Plastic hose from dish machine stuck into floor sink drain touching the bottom of the drain with no air gap (corrected) • Plastic piping touching bottom of drain (corrected) • Multiple small plastic service bowls with worn glaze, heavily scored and pitted (discarded and replaced) 3. RCC Main Kitchen and Dining Area • Multiple cutting boards heavily scored and/or stained • Sauté pans scored/scraped with non-stick coating damaged • Oven mitts damaged/worn/holes • Large gap in ceiling tile where electrical conduit enters/exits kitchen • Cracked/missing cove base tile at kitchen entry threshold • Missing caulking/seal in freezer holding ice cream with frost/ice buildup • Dish machine serviced to ensure sanitizing temperatures =180°F; test strips purchased 4. RCC Main Dry Storage Area • Light switch and electrical outlet with missing or damaged outlet cover • Metal racks with worn, peeled, and frayed tape replaced or cleaned to maintain smooth surfaces. 5. RCC floor kitchenette * Large hole found by piping of dish washer has been repaired; * Multiple cabinets observed with porous wood exposed where protective coating had worn or pealed; and * Large section of countertop by stove area was found with porous wood exposed will be repaired by 1/15/2025 or Kitchennette will be closed until repairs occur without interruption of services to residents. Audit and Additional Actions (1/07/2026) • All undated, uncovered, and improperly stored food items and equipment discarded; staff retrained on proper dating, labeling, and covering food and slicer when not in use • Dishwashing racks relocated to approved shelving • Oven racks relocated from floor to proper storage • Damaged equipment replaced or discarded • Water-damaged walls repaired and sealed • Freezer defrosted, sanitized, and serviced • Dish machine serviced to ensure sanitizing temperatures =180°F; test strips purchased • Improper food handling corrected; gloves enforced; hair restraints implemented (beard nets) • Electrical outlet and switch covers repaired SYSTEMIC CORRECTION TO SUPPORT SUSTAINED COMPLIANCE: • Kitchen Sanitation & Food Safety Policy revised with daily checklists and weekly deep-clean protocols • No Bare-Hand Contact policy retrained and enforced • Facial hair restraint policy reissued • Daily Sanitation Checklist implemented; Weekly Deep-Clean Protocol added • Monthly QA audits and quarterly environmental inspections scheduled • Repair & Replacement Log created for equipment and utensils • Staff retraining on Food Sanitation Rules and hygiene requirements • New employee orientation materials updated to include strengthened sanitation procedures EVALUATION FREQUENCY AND RESPONSIBILITY: Daily: • Sanitation checklist completed by staff; dish machine logs reviewed by kitchen supervisor or designee Weekly: • Executive Chef and Administrator (or Assistant Administrator) conduct walkthroughs and deep-clean verification Monthly: • Dining Services Director performs QA audits; Maintenance inspects plumbing and walls • Administrator reviews audit results with Executive Chef or designee Quarterly: • Preventive maintenance for structural integrity • QA Committee reviews findings monthly; retraining triggered by non-compliance RESPONSIBLE STAFF • Dining Services Director: Oversees QA audits and compliance • Executive Chef: Conducts daily and weekly sanitation checks • Maintenance Team: Handles monthly inspections and repairs • All Dietary Staff: Complete daily checklists and follow updated protocols • Administrator or designee: Reviews weekly and monthly audit results at QAPI meetings until sustained compliance is achieved Full compliance expected by January 18, 2026.

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, interview, and record review, it was determined the facility failed to ensure injuries of unknown cause and resident-to-resident altercations were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office as required for 1 of 1 sampled memory care resident (#8) whose incidents were reviewed. Findings include, but are not limited to: Resident 8 was admitted to the facility in 10/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 06/10/23 service plan, 03/26/23 through 06/26/23 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident was noted to be confused, required one to two staff assistance for ADL care, and needed frequent redirection by staff throughout the day. The resident could not make his/her needs known, inconsistently answered yes/no questions appropriately, and had frequent agitation. The resident had frequent physical and verbal aggression towards staff, including hitting, yelling, throwing dishes and ramming others with his/her walker or wheelchair. a. Review of the resident's records showed the following: * An incident report dated 04/12/23 indicated the resident was found on the floor on 04/01/23. The investigation was not completed until 04/12/23; * An incident report dated 05/02/23 indicated the resident was found on the floor on 04/28/23, no injuries were noted. The investigation was not completed until 05/16/23; * An incident report dated 05/01/23 indicated the resident had an assisted fall, no injuries were noted. The investigation was not completed until 05/16/23; * An incident report dated 05/09/23 indicated the resident had an assisted fall to the ground outside. No injuries were noted. The investigation was not completed until 05/16/23; * An incident report dated 05/11/23 indicated the resident had an assisted fall to the floor. No injuries were noted. The investigation was not completed until 05/16/23; * An incident report dated 05/22/23 indicated the resident had a fall in his/her room. No injuries were noted. The investigation was not completed until 06/20/23; * An incident report dated 05/27/23 indicated the resident was found on the floor in the living room. No injuries were noted. The investigation was not completed until 06/16/23; * An incident report dated 06/04/23 indicated the resident threw himself/herself out of the wheelchair while experiencing a hallucination. No injuries were noted. The investigation was not completed until 06/20/23; * An incident report dated 06/06/23 indicated the resident was found on the floor near the couch. No injury was noted. The investigation was not completed until 06/22/23; and * An incident report dated 06/08/23 indicated the resident sustained skin tears to the right shin when his/her leg fell down between the foot rest and chair. The investigation was not completed until 06/13/23. The investigations were not completed promptly after the incidents, to rule out abuse and neglect and to determine actions to prevent reoccurrence as a result of the incidents. b. Additional review of the resident's progress notes and investigations showed the following: * A progress note dated 04/06/23 indicated the resident was involved in a resident-to-resident altercation. Resident 8 grabbed another resident's arm while yelling at them and was extremely agitated with staff. No investigation was completed of the altercation, and it was not reported to the local SPD office. * A progress note dated 04/11/23 indicated the resident was involved in a resident-to-resident altercation. Resident 8 was hit in the face by another resident and Resident 8 was agitated and upset. No investigation was completed of the altercation, and it was not reported to the local SPD office. * An incident report dated 05/16/23 indicated the resident was found to have a skin tear and had a fall the night before. No injury was noted for the fall of 05/15/23. The investigation of the skin tear found on 05/16/23 was not completed until 05/23/23. A progress note dated 05/19/23 indicated a new skin tear was sustained to the forearm. The investigation was unclear how many skin tears were found and how they occurred. The investigation was unclear how abuse and neglect was ruled out and any further information about the previous fall's relationship to the new injuries. * A progress note dated 06/05/23 indicated the resident was involved in a resident-to-resident altercation. Resident 8 chased and kicked another resident in the memory care as well as chasing and striking out at staff at the time. No investigation was completed of the altercation, and it was not reported to the local SPD office. * An investigation dated 05/15/23 indicated the resident sustained a fall in the courtyard. Another resident witnessed the fall and stated the resident caught his/her walker on a corner and fell. No injuries were noted. In an interview on 06/28/23, Staff 1 (Director of Health Services) indicated at the time of the fall there were deep edges along the sidewalk which the resident caught his/her walker on. Staff 1 stated the maintenance director rectified the issue at the time of the resident's fall. Staff 1 acknowledged the investigation did not address how the resident fell or properly rule out abuse and neglect. The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD as needed was discussed with Staff 1 (Health Services Director), Staff 2 (Clinical Services Manager), and Staff 4 (Resident Care Manager/LPN) on 06/28/23. The staff acknowledged the findings. Staff 1 was asked to report the five incidents and provided confirmation of the reports prior to survey exit.

C231 Abuse Reporting & Investigation Action(s) taken: 1. The Fall Scene Investigation (FSI) form's high reliability organization checklist was updated to clarify identification of abuse and neglect along with the self-reporting process. Screening takes place at the time of the event by the first responder and is double checked by the licensed nurse or shift lead who is on duty at the time with instructions to report unknown cause and suspicions of abuse or neglect. The findings are then reviewed and confirmed when the investigation is completed.  The revised form was re-distributed to clinical staff on 7/6/23 for immediate use. 2. Facility's Abuse Reporting and Investigation policy and procedure was updated to clarify process for facility self-reports for unknown cause and suspected abuse or neglect events and new FSI form was attached. Policy to be re-distributed to clinical staff 7/14/23. 3. Med Techs were re-educated 7/14/23 on importance of reporting resident to resident interactions to a supervisor, or a person in charge if after hours, immediately. 4. Charge nurses were also instructed to utilize "Safety/Security/Conduct" incident report in electronic event reporting tool to initiate investigation. System correction: 1. Fall scene investigation (FSI) form updated and is required to be completed by first responder before end of shift on day of incident per policy. 2. FSI form instructions expanded for Charge Nurse or shift lead to screen for unknown cause and suspected abuse or neglect (including failing to follow service plan) and more specific follow up instructions to complete by end of shift same day as incident; notify supervisor or on-call individual immediately if applicable. 3. Reporting and Investigation policy updated to clarify resources for follow up outside of business hours. 4. Lead pocket guide is always available in charge nurse office and instructs the charge nurse or shift lead when and how to contact a nursing supervisor or designated on-call leader. Method & frequency of evaluation: 1. Charge nurses or shift leads to monitor completion of FSI forms with preliminary abuse and neglect screening and follow up guidance prior to end of shift. Charge Nurses to assure completion of all fields in FSI form which include double-checking screening for abuse and neglect. 2. Third check added to FSI checklist for Nurse Manager to review Reporting and Investigation protocol and assure self-report was completed for any incident with cause unknown or suspected abuse or neglect 3. Electronic clinical care dashboard is monitored weekdays for high priority progress notes (includes behavior notes) by clinical leadership 4. Care managers monitor progress notes weekdays Responsible person(s): Care Coordinator, Care Manager, Clinical Manager, Health Services Director

2.  Resident 4 was admitted to the facility in February 2023 with diagnoses including dementia, impaired mobility, obstructive sleep apnea, and major depressive disorder. The resident's current service plan, dated 05/23/23, was reviewed, observations were made, and interviews were conducted between 06/26/23 and 06/28/23. Resident 4's service plan was not reflective and did not provide clear instruction to staff in the following areas: * Two-person assist with transfers, brief changes, and dressing; * Specific assistance needed with incontinence care provided in bed; * Use of tilt-in-space wheelchair; * Enjoyed participating in music activities; and * Ability to use the call light. The need to ensure resident service plans were reflective of current status and care needs, and provided clear direction to staff was reviewed with Staff 1 (Director of Health Services), Staff 4 (Resident Care Manager/LPN), and Staff 9 (Resident Care Coordinator) on 06/28/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services, and were implemented by staff for 2 of 7 sampled residents (#s 4 and 8). Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 10/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan, dated 06/10/23, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not consistently implemented by staff in the following areas: * Hearing aides; * Fall risk interventions, including fall mat and motion mat; * Behaviors, including aggression toward staff, hitting and kicking; * Bathing and toileting assistance; * One- versus two-person transfer assistance and gait belt use; * Wheelchair versus walker use; * Dining preferences including use of finger foods versus utensils, use of paper plates and plastic utensils, favorite foods to help with refusals, and location of meals; and * Hospice comfort care interventions, including floating heels when laying down, repositioning every two hours, and oral care every two hours. The need to ensure service plans were reflective of current care needs, provided clear direction to staff, and were implemented by staff was discussed with Staff 1 (Director of Health Services), Staff 2 (Clinical Services Manager), and Staff 4 (Resident Care Manager/LPN) on 06/28/23. They acknowledged the findings.

C260 Service Plan: General Action(s) taken: 1. New Care Manager for resident # 8 has provided hands-on care theirself, re-evaluated resident, and revised service plan to more accurately reflect resident's care and individual needs as of 7/5/23. 2. Resident Care Manager for resident #4 interviewed caregivers and provided resident hands-on care theirself in order to evaluate accuracy of service plan. SP was accurate with the exception of 1 care area, toileting, and this area was updated as of 7/5/23. 3. Care staff have been re-instructed in July 2023 monthly inservice to notify Care Coordinator or Care Manager when a resident's actual care needs have changed or are not accurately reflected on their service plan. System correction: 1. New Resident Care Manager for memory care neighorhood has scheduled re-evaluation and service plan update as applicable for all residents in care area, to be completed by 8/1/23. 2. Quarterly evaluations, service plan updates and care conference will proceed on schedule under new RCM's experienced leadership. 3. Annual caregiver in-service training on the topic of what to document, observe for, and notify the licensed nurse of, is scheduled for each January. 4. Onboarding and annual required training plans include a module on "Monitoring Changes in Condition." 5. See also C231 for system corrections to falls investigations and Z164 for Activities.   Method & frequency of evaluation: 1. Admission, quarterly, and change of condition evaluation and service plan updates are scheduled automatically in electronic medical record, visible on EMAR dashboard to be monitored by RN and Care Managers. Responsible person(s): Resident Care Managers, Clinical Services Manager (RN), Health Services Director

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, and progress was documented weekly until resolution for 1 of 1 sampled memory care resident (#8). Findings include, but are not limited to: Resident 8 was admitted to the facility in 10/2022 with diagnoses including dementia. Interviews with staff and review of the resident's 06/10/23 service plan, 03/26/23 through 06/26/23 progress notes, incident investigations, and physician communications were completed. a. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness, and/or lacked resident-specific directions to staff in the following areas: * New medications and medication changes; * Injury and non-injury falls; * Skin issues, including skin tears; and * Behaviors, including resident-to-resident altercations. b. The resident experienced non-injury falls on 03/29/23, 04/01/23, 04/28/23, 05/01/23, 05/09/23, 05/10/23, 05/11/23, two falls on 05/16/23, 05/22/23, 05/27/23, 06/06/23, and 06/07/23. There was no documentation in the resident's record the facility had promptly documented complete investigations of the falls to determine the cause, minimize reoccurrence, determine actions and interventions, and communicate them to staff for each fall. c. The resident experienced a severe weight gain of 11.8 pounds, or 8.8%, from 05/08/23 to 06/03/23. In interview on 06/28/23, Staff 2 (Clinical Services Manager) indicated she was not aware of the weight changes for the resident and had not completed an assessment of the changes. The need to ensure short-term changes of condition had weekly progress documented until resolution, provided clear, resident-specific directions to staff, and significant changes were reported to the RN for assessment was discussed with Staff 1 (Director of Health Services), Staff 2, and Staff 4 (Resident Care Manager/LPN) on 06/28/23. The staff acknowledged the findings.

C270 Changes of Condition & Monitoring Action(s) taken: 1. Weight change assessment and change of condition assessment completed for Resident #8 by RN on 6/29/23. Weight inaccuracies were indentified and new scale for memory care area has been ordered. 2. Weight data collection system revised, see system correction below. 3. New RN is enrolled in "Nursing Practice in Community Based Care" course, attended July 11-13. 4. Chair scale to be removed from memory care due to questions regarding accuracy, to be replaced with wheelchair scale (on order). 5. Re-education of charge nurses to use email distribution group for "Nursing Supervisors" and to notify Clinical Services Manager, Care Manager and Administrator of changes in condition and other critical clinical issues per Lead Pocket Guide. System Correction: 1. Weights system correction a. First Monday of the month: Care Coordinators will obtain resident's weights. They will have a weights history list printed off so they can see if there are any big discrepancy in weight. If a weight seems off, they will reweigh the resident at that time. By the end of the business day, the list of weights will get input into the EMAR by the Care Coordinators. b. First Tuesday of each month: the Care Managers (licensed nurses) will review weights and evaluate those that may constitute a significant change. c. First Wednesday of each month: Care Managers and facility RN will meet to review weights, allowing for RN input and opportunity to document an initial note addressing weight changes before the end of Wednesday (within 48 hours of identification). d. Care Coordinators will follow up with residents who are unavailable on the first Monday, track their return to the facility and obtain their weight at that time. Care Managers and RN to follow the process above for those that were unavailable on "weigh-in Monday." 2. Alerts and Tasks (Temporary Service Plans) are created in the EMAR for monitoring and caregiver information related to changes in condition. Care Coordinators and Care Managers review these together daily, and as a group with the RN three times a week. 3. Resident Care Managers update service plans with resident-specific interventions to address changes in condition as applicable. 4. Documentation of changes in condition includes weekly progress notes by a trained, experienced staff until the condition is resolved or represents a new baseline or permenent change. 5. The RN assessment consists of information to assure essential care needs are identified, the service plan is updated and interventions are implemented in response to the significant change of condition. Method & frequency of verification: 1. Care Coordinators to track residents weighed in their respective neighborhood on the first Monday of each month, follow up with those who were unavailable, and assure all resident weights are reported to the Care Manager either on the first Monday of each month or upon the resident's return to the facility. 2. Care Managers to track and assure that all potential significant weight changes, and all other potential significant changes in condition, are referred to the RN in writing. 3. RN to track change of condition referrals and cross-check with 24-hour reports. Responsible person(s): Resident Care Managers, Clinical Services Manager (RN), Health Services Director

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled memory care residents (#8) who experienced significant changes of condition. Findings include, but are not limited to: Resident 8 was admitted to the facility in 10/2022 with diagnoses including dementia. Weight records, dated 03/03/23 through 06/28/23, and progress notes, dated 03/26/23 through 06/26/23, indicated the resident experienced the following: * An 11.8 pound weight gain between 05/08/23 and 06/03/23, which constituted an 8.8% gain in one month. Progress notes, temporary service plans, and physician communications dated 03/26/23 through 06/26/23 indicated the resident had experienced a recent decline in ADL abilities, as well as an increase in behaviors and agitation. The resident was admitted to hospice services on 06/10/23. Multiple observations of the resident between 06/26/23 and 06/28/23 showed the resident attended all meals served in either the living room or the dining room. Staff sat with the resident for all meals and assisted the resident to eat. The resident inconsistently initiated intake and primarily used his/her fingers to eat rather than utensils. The resident ate less than 25% at the meals observed. In interviews between 06/26/23 and 06/28/23, Staff 20 (CG), Staff 16 (CG), Staff 24 (CG), Staff 10 (LPN), and Staff 25 (Agency CNA) indicated the resident's intake varied and that s/he became overwhelmed if there was too much activity or noise. The resident was not able to consistently make his/her needs known. The staff indicated the resident frequently used his/her fingers to eat, regardless of what type of food was being served. The staff further indicated the resident required staff assistance with his/her meals to ensure any intake occurred. In interview on 06/28/23, Staff 2 (Clinical Services Manager) indicated she was not aware of the weight changes for the resident and had not completed an assessment of the changes. She questioned the accuracy of the weight as the resident's intake was poor and s/he did not typically have issues with edema. The facility failed to ensure an RN assessment was completed for the weight gain from May 2023 to June 2023 which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1(Director of Health Services), Staff 2, and Staff 4 (Resident Care Manager/LPN) on 06/28/23. The staff acknowledged the findings.

C280 - Resident Health Services See C270

Based on interview and record review, it was determined the facility failed to develop a staffing plan based on care minutes calculated by the acuity-based staffing tool (ABST) and to update the ABST to accurately reflect the time needed to provide care for 6 of 7 sampled residents (#s 2, 4, 5, 7, 8, and 9). Findings include, but are not limited to: The facility's ABST was reviewed with Staff 1 (Health Services Director) on 06/27/23 and 06/28/23. Staff 1 reported the facility was not staffing according to the plan generated by the ABST. She stated medication administration times were not included in the minutes by which the ABST calculated a staffing plan. Staff 1 indicated the facility was struggling to determine the number of minutes for the required 22 ADLs. ABST data for seven sampled residents (#s 1, 2, 4, 5, 7, 8, and 9) was reviewed. For six of the seven residents the data was not reflective of their current care needs. The need to ensure ABST entries accurately reflected resident care needs and a staffing plan was developed based on the ABST data was discussed with Staff 1 (Health Services Manager), Staff 2 (Clinical Services Manager), and Staff 5 (Resident Care Manager/LPN) on 06/28/23. They acknowledged the findings.

C361 Acuity-Based Staffing Tool Action(s) taken: 1. The Health Services Director sought consultation with the Department's  ABST Policy Analyst and as a result: a. Revised facility ABST procedure to include medication administration and documentation of regular updates. b. Advised Care Managers to work with Care Coordinators to return medication administration/med tech time to the ABST and to double check to assure that the ABST and each resident's service plan match. c. Revised internal facility tracking spreadsheet to better compare facility direct care worked hours (excluding unpaid lunch breaks) to ABST recommended hours thereby assure facility staffing plan exceeds ABST. System correction: 1. Policy and procedure reflects recommendations from ABST Policy Analyst and survey coordinator. 2. Revised internal facility instructions for completion of ABST, was discussed with and distributed to those responsible for updating data regularly. 3. Links to the 4/26/23 ABST ODHS Training Hour presentation and 09/22 Provider Guide were added to the internal facility instructions for easy access by all internal users. 4. Uploaded or updated the 4/26/23 ABST ODHS Training Hour presentation and 09/22 Provider Guide as attachments to facility policy and procedure for easy access by all internal users. Method & frequency of evaluation: 1. ABST data and facility staffing calculations are compared weekly and adjustments to staffing plan are made accordingly. 2. Administrator to assure that weekly staffing levels exceed ABST recommendation. Weekly checks will assure that posted staffing plan takes ABST data into consideration, that the staffing plan is re-posted as indicated, and that the facility is consistently staffing to the posted staffing plan. 3. Resident Care Managers to audit approximately 5% of ABST questionnaires (approximately 4.25 residents) per month to compare questionnaire responses and service plans to assure accuracy. Responsible person(s): Care Coordinators, Resident Care managers, Clinical Services Manager, Health Services Director

Based on observation and interview, it was determined the facility failed to ensure outside surfaces were maintained in good repair. Findings include, but are not limited to: The courtyard of the MCC was toured on 06/26/23. There were drop-offs of up to one to three inches along the edges of the pathways of the courtyard. This created a potential tripping hazard for residents. The drop-off areas were shown to and discussed with Staff 1 (Director of Health Services), Staff 3 (MT), and Staff 12 (Facility Services Supervisor) on 06/28/23. They acknowledged the findings.

Action(s) taken: 1. Work order submitted: a. Gardenview walkway path drop off  was evaluated by maintenance supervisor and landscaping supervisor. Landscaping contractor is now aware they are responsible to monitor and repair excessive drop offs. All are scheduled for repair by 8/1/23. b. Drop offs inside walkway circle were caused by shrinkage due to lack of irrigation which had been cut off by construction. Irrigation has been repaired. System correction: 1. Landscaper to fill sidewalk drop offs. Company now understands necessity to prevent tripping hazards and to repair any that develop in the future. 2. Landscaper to report malfunctioning irrigation system to maintenance supervisor for immediate repair. 3. Maintenance supervisor has created a Preventative Maintenance schedule to have sidewalk drop offs evaluated by facility maintenance personnel and schedule regular sidewalk pressure washing. Method & frequency of evaluation: 1. Landscaper will evaluate drop offs during weekly lawn maintenance. 2. Facility maintenance personnel is scheduled to check drop offs once a month during inspection and following power washing. Responsible person(s): Maintenance supervisor, Facilities Director, Health Services Director

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to: Observations made on 06/26/23 revealed the following areas needed cleaning or repair: A. On the third floor Residential Care Facility (RCF) unit: * The chair rails in the common area near nurse's station and near the exam/medication room were chipped, scratched, and rough to touch. * The two elevator door frames were chipped and scratched. B. On the second floor RCF unit: * The two elevator door frames were chipped and scratched. C. On the MCC unit: * The second column in hallway had a chipped edge of drywall and paint. * The exit side of the door to the Health Center was scratched and had chipped paint. The environment was toured on 06/28/23 with Staff 1 (Director of Health Services), Staff 3 (MT), and Staff 12 (Facility Services Supervisor). The need to ensure all interior and exterior materials and surfaces were kept clean and in good repair was discussed with Staff 1, Staff 3, and Staff 12. They acknowledged the findings.

Action(s) taken: 1. Work order submitted: a. Gardenview paint and wall repairs to be completed by 8/1/23. b. RCC chair rail repair and elevator door frames to be painted and/or touched up by 8/1/23. System correction: 1. Maintenance supervisor to schedule facility painter to routinely inspect wall finishes in licensed care areas for need of repair or touch up and to correct as applicable. 2. Maintenance supervisor to schedule facility maintenance personnel to routinely inspect for physical plant items that are not clean or in good repair and to correct as applicable.   3. Administrator to train new maintenance crew members on environmental requirements Method & frequency of evaluation: 1. Inspections and repairs by painter and maintenance personnel will be scheduled in licensed neighborhoods quarterly by way of facility preventative maintenance software. Responsible person(s): Maintenance Supervisor, Facilities Director, Health Services Director

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 C231, C361, C510, and C513.

Z 142 - Administration Compliance See C231, C361, C510, C513

Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation and dementia training completed, demonstrated competency in assigned duties within 30 days of hire for 3 of 3 newly hired direct care staff (#s 26, 27, and 28), and a total of 16 hours of in-service training completed annually, including six hours related to dementia care topics, for 3 of 3 long-term direct care staff (#s 6, 18, and 30). Findings include, but are not limited to: Staff training records were reviewed with Staff 11 (HR Staffing Coordinator) on 06/28/23. The following deficiencies were identified: a. There was no documented evidence Staff 26 (Cook), Staff 27 (CG), and Staff 28 (CG) hired 08/13/22, 02/11/23, and 04/18/23 respectively, completed one or more of the following pre-service orientation topics prior to beginning their job duties: * Abuse reporting requirements; and * Written job description. b. There was no documented evidence Staff 27 and Staff 28 completed the following dementia care training topics prior to providing resident care and services to residents independently: * Dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach; * Environmental factors which are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors which indicate a change in the resident's condition and report behaviors which required on-going assessment; * How to provide personal care to a resident with dementia including an orientation to the residents service plan; and * Use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 27 and Staff 28 demonstrated competency in one or more assigned duties within 30 days of hire: * Conditions which require assessment, treatment, observation, and reporting; * General food safety, serving, and sanitation; and * Other duties as applicable, including safe medication and treatment administration. d. There was no documented evidence Staff 6 (RCC), hired 12/07/19, Staff 18 (CG), hired 03/19/18, and Staff 30 (CG/MT), hired 11/20/19, completed 16 hours of annual in-service training which included at least six hours of dementia care training. The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (Director of health Services) and Staff 11 on 06/28/23. They acknowledged the findings.

Z155 Staff Training Action(s) taken: 1. The erroneously removed pre-service dementia training has been returned to the onboarding training plan and assigned as required for employees who missed it and will be completed by 8/25/23. 2. Skills checkslists will be/have been updated to include both employee's initials/signatures. 3. Monthly inservice content, agenda and length of time are now being added to the Relias attendance module. System correction: 1. Skills checklist audits will assure they are signed off by both the trainee and trainer and completed by the fourth shift of on-the-floor training. Completed checklists are uploaded into Relias for tracking and visibility on employee transcript. 2. Required dementia trainings are assigned automatically to applicable new hires in Relias. New employees are not released for training on the floor until all Relias trainings are completed. All onboarding training, including the dementia training module, is required to be completed within 30 days of hire and, per Friendsview policy, must be completed before new employees can be scheduled for on-the-floor training. 3. Staffing coordinator will maintain an Inservice Tracker and notify supervisors monthly of compliance/non-compliance for individual employees. Supervisors will follow up with individual employees through Coaching for Success program. Method & frequency of evaluation: 1. Department Staffing Coordinators, in collaboration with Human Resources, will verify all onboarding trainings have been assigned and completed by applicable employees within time required. 2. Dining Services department will upload food Handler Cards into Relias to make them readily available and to track compliance of renewals. 3. Monthly required inservices are being tracked via a, new to us, system in Relias called "requirement tracker." A list of noncompliant employees is being generated for supervisors. If the employee does not complete the make-up training as assigned by the end of the month, the staffing coordinator will remove them from the schedule until they do. Responsible person(s): Care Coordinators, Care Managers, Clinical Services Manager, Staffing Coordinators, Health Services Director, Senior Administrative Leadership Team

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 C260, C270, and C280.

Z 162 - Compliance with Rules Health Care See C260, C270, C280

Based on interview and record review, it was determined the facility failed to evaluate residents for activities, to develop individualized activity plans from the evaluations, and ensure a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate based on residents' evaluations for 1 of 1 sampled memory care resident (#8) whose service plan was reviewed. Findings include, but are not limited to: A review of the service plan for Resident 8 and an interview with Staff 13 (Therapeutic Rec Coordinator) and Staff 14 (Therapeutic Rec Assistant) on 06/27/23 revealed the following: A. The facility had not completed an activity evaluation which addressed the following: * Past and current interests; * 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. B. There was no documented evidence an individualized activity plan had been developed based on their activity evaluation which was reflective of the resident's activity preferences and needs. C. There was no documented evidence a selection of daily structured and non-structured activities were provided and included on the resident's activity service or care plan as appropriate and based on the resident's evaluation. The need to ensure the facility completed an activity evaluation addressing the required elements, developed an individualized activity plan based on the evaluation for each resident, and provided daily structured and non-structured activities based on the evaluation was discussed with Staff 1 (Director of Health Services), Staff 2 (Clinical Services Manager), and Staff 4 (Resident Care Manager/LPN) on 06/28/23. They acknowledged the findings.

Z164 Activities Action(s) taken: 1. Recreation/Activities Evaluation form has been updated for ease of use and to assure all required elements are included. 2. Recreation Coordinator to reevaluate all residents and update service plans based on updated evaluation. 3. Recreation Coordinator and new Resident Care Manager for resident #8 identified activities as behavior interventions. 4. Recreation Coordinator and new Resident Care Manager reviewed recreation supplies and resources available for spontaneous activities between structured events available to resident #8 and all memory care residents. 5. New Resident Care Manager has identified multiple caregiver-driven spontaneous activities to support residents and has begun to teach caregivers about them, directing them toward available tools and resources. System correction: 1. Recreation evaluation form and review schedule added to electronic medical record. 2. Activities service plan in electronic medical record has been updated to prompt for, at a minimum, person-centered activity preferences, interests and needs, current abilities and skills, social and emotional needs and patterns, physical abilities and limitations, necessary adaptations, and activities identified as behavioral interventions. Method & frequency of evaluation: 1. Scheduled evaluations and service plan updates will be monitored monthly in electronic medical record to assure completion. Responsible person(s): Therapeutic Recreation Coordinator, Community Life Director, Health Services Director

The findings of the re-licensure survey, conducted 06/26/23 through 06/28/23, 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 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 06/28/23, conducted 11/20/23 through 11/21/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and storage practices prevented cross contamination in accordance with the Food Sanitation Rules OAR 333-150-0000. Finding include, but are not limited to: On 10/19/22 at 9:45 am, the facility kitchen was observed to need cleaning in the following areas: * Mini refrigerator - front doors had food splatters; * The side of the ice machine had build up of hard water stains; * The plexi glass next to the hand washing sink in dish room had build up of hard water stains; * Walk in refrigerator floor had food debris; * Kitchen floor had food debris throughout; and * Dish room floor had food debris, hard water stains on the equipment. The following practices failed to prevent the potential for cross contamination: * One staff was observed to towel dry dishes rather than let air dry. * Large container of lettuce prepped for service was not covered securely in the walk in refrigerator: * A bucket of panko crumbs was not covered in the dry food storage area. The areas identified above were discussed with Staff 1 (Health Service Director) and Staff 2 (Dining Service Director) on 10/19/22. The findings were acknowledged.

Actions Taken: The surveyor observed the food preparation area during the noon meal preparation time which fell between the 9am and 12pm cleaning breaks. As could be expected, food spatter and debris were the result of food preparation currently in progress. Per policy, the Take 5 program mentioned in the citation and system correction section below, at 12pm on 10/19/22 the food debris was swept up and the food splatters on surfaces wiped away. The hand wash station plexiglass shield and other areas with visible hard water stains were cleaned and sanitized immediately after the surveyor's departure and again per daily cleaning schedule with approved, food-safe products on 10/19/22. Hard water marks are resistant to these products and are not an indication of failure to meet this requirement. The noted hand wash plexiglass "stains" were actually water splash marks, a product of multiple people having washed their hands already that day. The Plexiglass was washed immediately following the survey on 10/19/22with safe, approved products and the dried water marks were removed. The food item lids were righted to cover contents completely during the survey. The lettuce container and the panko containers are to be replaced. Replacement containers with lids that fit more snuggly and incapable of being accidentally knocked off or left askew have been ordered. New containers expected to arrive by November 30, 2022. In regards to the comment of a staff member drying dishes with a towel: The staff member was talked to in a follow up by senior management on 10/19/22. The staff member, who is a ServSafe certified supervisor, stated he was not drying dishes with a towel. He stated he was polishing silverware with the polishing rag. He reassured us that he knows our policy that dishes cannot be dried with a towel and that they must be air-dried. System Correction: There is a regularly maintained water softer filtration system currently installed and connected to the hot water tank that supplies the kitchen. The entire kitchen was professionally deep cleaned on September 15th, 2022 and is scheduled to annually. Daily cleaning schedule (Take 5 program) consists of all staff stopping their work and cleaning their designated stations at 9am, 12pm and 3pm. The daily closing duties include, but are not limited to, cleaning of all surfaces such as sinks, kitchen stations, the buffet table, and all floors both front and back of house. Method of Evaluation: Supervisors do a nightly walk through before leaving at the end of the day to ensure all cleaning described above was done properly. There is a weekly cleanliness audit performed that gets reviewed and followed up as applicable by the Bon Appetit safety committee. There is a more detailed monthly audit completed for each of the kitchens that is also reviewed and followed up on as applicable by the Bon Appetit safety committee. The Department has daily team meetings at 10am and 4pm to communicate cleaning and safety standards. The Department has a Person in Charge for every meal service to observe for and ensure food safety and sanitation. Person(s) responsible for completion/monitoring: Dining Services Director, Executive Chef, Sous Chefs, Shift Supervisor(s), Person in Charge.

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

Refer to C240

The findings of the kitchen inspection, conducted 10/19/22, 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 Service - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 10/19/22, conducted on 12/14/22, are documented in this report. The facility was found in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.