Mt Angel Towers

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair, and proper food handling procedures were followed in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 06/16/25 at 11:00 am the main kitchen and walk-in refrigerator and freezer were observed to need cleaning and repair in the following areas:

a. Kitchen area:

* Pipes and the floor behind multiple appliances had grease, dirt, and debris on them;

* The air filters on the window air conditioning units were covered with dust;

* Multiple ceiling light fixtures contained dead insects or were missing covers;

* The electric fan on the floor next to the serving and plating line was covered with dust; and

* Wall under the sink adjacent to the plating area had a large gap around the sink drain pipe.

b. Walk-in refrigerator and freezer:

* Floor of the walk-in freezer contained debris and dirt;

* The rubber seal on the door of the walk-in freezer was worn and not air-tight, allowing airflow into the freezer and build up of frost on the internal freezer door; and

* Frost was accumulated on the ceiling and the three fans inside the walk-in freezer.

On 06/16/25 at 11:00 am, the following improper food handling practices were noted:

* Individual portions of food were plated on trays in the walk-in refrigerator and left uncovered.

The findings were discussed with Staff 2 (ED) and Staff 6 (Executive Chef) on 06/17/25 at 9:43 am. Both 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, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to

1. Resident 4 was admitted to the facility in 05/2023 with diagnoses including insulin-dependent diabetes mellitus type 2, systolic (congestive) heart failure, and chronic obstructive pulmonary disease (COPD).

Observations were made of the resident's care on 06/17/25 and 06/18/25, interviews with the resident and facility staff were conducted, and the service plan, dated 06/06/25, was reviewed.

Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Instructions on signs and symptoms of hypo- and hyperglycemia to report;

* Instructions for proper maintenance of blood sugar monitor on right upper extremity and how to monitor for malfunctions;

* Instructions to staff on blood glucose monitoring protocol when resident skipped meals;

* Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety;

* Instructions for aspiration precautions and interventions while choking;

* Physician Orders for Life Sustaining Treatment status;

* Instructions on signs and symptoms of depression to report while on anti-depressant therapy;

* Instructions on to whom to report weight gain or loss, and changes in appetite;

* Instructions on edema management;

* Instructions on fall prevention;

* How nebulizer device was to be used and monitored for safety.

* History of dehydration;

* Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort;

* How a person expressed memory loss;

* Instructions on to whom to report skin impairments;

* Personality, including how the person coped with change or challenging situations;

* Instructions on peri and skin care;

* Skin monitoring; and

* Electric wheelchair equipment precautions and instructions for proper maintenance.

The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Administrator) and Staff 5 (RCC) on 06/18/25 at 12:43 pm. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 09/2022 with diagnosis including osteoarthritis and hypertension.

Review of the resident’s progress notes and service plan, dated 05/03/25, and interviews with staff and resident revealed the service plan was not reflective or did not provide clear instructions to staff in the following areas:

*Activities; and

* Catheter care.

The need to ensure service plans reflected resident’s current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (Administrator) on 06/18/25 at 2:15 pm. She acknowledged the findings.

3. Resident 2 was admitted to the facility in 10/2018 with diagnoses of hypertension, cardiac arrhythmia, and mild cognitive impairment.

Review of Resident 2’s service plan, dated 05/12/25, progress notes, dated 03/16/25 through 06/16/25, and interviews with staff and the resident revealed the service plan was not reflective, or did not provide clear instruction to staff in the following areas:

* Activities;

* Dining;

* Transfers;

* Fall interventions; and

* Behaviors.

On 06/18/25, the need to ensure service plans were reflective and provided clear instructions to staff was discussed with Staff 1 (Administrator) and Staff 2 (ED). They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document weekly progress until the condition resolved for 2 of 3 sampled residents (#s 2 and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 05/2023 with diagnoses including insulin dependent diabetes mellitus type 2, systolic (congestive) heart failure, and chronic obstructive pulmonary disease (COPD).

Resident 4's progress notes, dated 03/21/25 through 06/13/25, service plan dated 06/06/25, and post discharge skilled nursing facility orders were reviewed.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

04/15/25: “…[resident] noted that …weight was increased today (145 lbs [pounds]) as compared to previous days (139..), and [resident] has been experiencing shortness of breath w[wild]/mild exertion in the past two weeks…”;

04/18/25: Metolazone (for fluid retention) was discontinued;

04/21/25: “noted hypertension… at the time when resident was noticing increased shortness of breath/work of breathing with mild exertion…”;

05/7/25: “coughing, scratchy throat, feels like [resident] caught a cold.”;

05/8/25: ED visit related to onset of cough;

05/13/25: admitted to hospital;

06/06/25: returned to the facility following hospitalization for

exacerbation of congestive heart failure and exacerbation of COPD with multiple medication changes;

06/13/25: “Resident reports continued “mild” burning with urination…”; and

06/13/25: “…resident reported that [medical doctor] verbally instructed [him/her] to discontinue potassium tablets…”.

The need to ensure the facility had a system in place to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document weekly progress until the condition resolved was discussed with Staff 1 (Administrator) and Staff 5 (RCC) on 06/18/25 at 12:43 pm. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 10/2018 with diagnoses including hypertension, cardiac arrhythmia, and mild cognitive impairment.

In an acuity interview on 06/16/25 at approximately 9:30 am, Staff 9 (MT) stated Resident 2 had challenging behaviors, including refusal of care, threatening statements to staff, and physical resistance of hands-on care. The resident was also identified as receiving PRN psychotropic medications to treat behaviors.

Review of Resident 2’s progress notes, dated 03/16/25 through 06/16/25, revealed the following documented entries from staff:

* 04/11/25: ”Resident showing increased signs of anxiety/agitation over the last several months”;

* 04/11/25: ”Behaviors include repeatedly pressing call light but stating [he/she] does not need assistance, slamming [his/her] walker up and down or ramming it into the wall when agitated”;

* 04/11/25: ”Resident will become agitated during transfers, has difficulty following directions, and will throw [his/her] body backwards towards bed or chair, buckle [his/her] knees mid-transfer, etc.”; and

* 06/12/25: ”Resident was having aggressive behaviors with the staff. [He/she] was spitting at the staff and was trying to hit them”.

There was no documented evidence resident-specific interventions were developed or implemented, or monitoring with weekly progress noted occurred for the above changes of condition.

On 06/18/25, the need to determine resident-specific actions or interventions needed to manage behaviors, communicate this information to staff on all shifts, and monitor the behaviors to resolution was discussed with Staff 1 (Administrator) and Staff 2 (ED). They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included resident-specific parameters and instructions for PRN medications and were kept for all medications that are ordered by a legally recognized prescriber and were administered by the facility for 2 of 3 sampled residents (#s 1 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 4's MAR from 05/01/25 through 06/16/25 and physician orders were reviewed and revealed the following:

a. The following PRN medications lacked instructions for sequential order of use:

* Milk of Magnesia 400mg/5ml (for bowel care); and

* Miralax Powder (for bowel care).

b. The following PRN medications lacked resident-specific parameters for use:

* Albuterol 0.083%/3ml (for wheezing and shortness of breath);

* Albuterol HFA 90mcg (for shortness of breath);

* Mylanta (for heartburn);

* Calcium Antacid 500mg (for upset stomach);

* Metolazone 2.5mg (for edema); and

* Neosporin (antibiotic ointment).

c. The order for continuous oxygen was not documented on the MAR.

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 5 (RCC) on 06/18/25 at 12:43 pm. They acknowledged the findings.

2. Resident 1’s MAR from 05/01/25 through 06/16/25 and physician orders were reviewed and revealed the following:

The following PRN medication lacked clear instructions for non-licensed staff:

* Diclofenac Gel 1% (apply 4 grams topically to the affected area twice daily as needed for pain).

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 5 (RCC) on 06/18/25 at 12:43 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to complete or update the ABST evaluation for each resident no less than quarterly, as required. Findings include, but are not limited to:

Review of the facility's ABST entries was completed and showed the following:

Updates to the ABST were not made at least quarterly (within last 90 days) for 14 of the 26 residents currently residing in the facility.

In an interview on 06/17/25 at 12:35, Staff 1 (Administrator) acknowledged the failure to update all residents in the facility ABST.

On 06/18/25, the need to ensure all ABST evaluations were updated at least quarterly was discussed with Staff 1 and Staff 2 (ED). They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics and pre-service dementia training had been completed prior to staff providing direct care to residents for 3 of 3 newly hired staff (#s 7, 12, and 14). Findings include, but are not limited to:

The facility's training records were reviewed on 06/17/25 and revealed the following:

A. Staff 7 (Life Enrichment), hired 03/11/25 lacked documented evidence s/he had completed the following:

* Resident's rights and values of CBC care;

* Abuse reporting requirements;

* Fire safety and emergency procedures;

* Infectious Disease Prevention (two-hour course);

* Approved HCBS course; and

* Approved LGBTQIAS+ course.

B. Staff 12 (CG), hired 04/17/25, lacked documented evidence s/he had completed the following:

* Resident's rights and values of CBC care;

* Abuse reporting requirements; and

* Fire safety and emergency procedures.

C. Staff 14 (CG), hired 05/14/25, lacked documented evidence s/he had completed the following:

* Infectious Disease Prevention (two-hour course);

* Approved HCBS course;

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

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

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

On 06/18/25, requirements for pre-service orientation and pre-service dementia training were discussed with Staff 1 (Administrator) and Staff 2 (ED). They acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service

(3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding:

(a) A review of their written position description with their job responsibilities.

(b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings.
(A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities.
(B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of
this rule.

(c) Abuse and reporting requirements.
(d) Fire safety and emergency procedures.

(e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease.

(A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:
(i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease.
(ii) Policy addressing respiratory hygiene and coughing etiquette.
(iii) Standard precautions.
(iv) Hand hygiene.
(v) Use of personal protective equipment.
(vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection.
(vii) Isolating and cohorting of residents during a disease outbreak.
(viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks
under ORS 433.004 and safeguards for employees who report disease outbreaks.

(B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.
(i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.
(ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.

(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below:
(A) Effective March 31, 2024, all staff must have completed the required training.
(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities.
(g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate.

(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.
(a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.
(A) Documentation of dementia training:
(i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training.
Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.
(ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.
(B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training.
(C) A certificate of completion must be made available to the Department upon request.
(D) Pre-service dementia care training must include the following subject areas:
(i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.
(ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.
(iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.
(iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:
(I) Identify and address pain.
(II) Provide food and fluids.
(III) Prevent wandering and elopement.
(IV) Use a person-centered approach.

(b) ORIENTATION TO RESIDENT. Pre-service orientation to resident:
(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan.
(B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 12 and 14) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 06/17/25 at 03:00 pm revealed the following:

There was no documented evidence Staff 12 (CG), hired 04/17/25, and Staff 14 (CG), hired 05/14/25, had demonstrated competency in all required areas and within 30 days of hire including:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

The need to document demonstrated competency of job duties within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 2 (ED) on 06/18/25. They acknowledged the lack of documented evidence the required training had been provided.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff

(5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF.
(a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned.
(b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to:
(A) The role of service plans in providing individualized resident care.
(B) Providing assistance with the activities of daily living.
(C) Changes associated with normal aging.
(D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition.
(E) Conditions that require assessment, treatment, observation and reporting.
(F) General food safety, serving and sanitation.
(G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised.

(9) ADDITIONAL REQUIREMENTS. Staff:
(a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services.
(b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required.
(c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed.

(10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule.
(a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 06/11/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 06/11/24, conducted 07/23/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The facility was found in substantial compliance.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:a. On 06/11/24 at 10:45 am, the facility kitchen was observed to need cleaning in the following areas: * Window screen in dishwashing area above clean dish area - significant build up of dust; * Door handles on refrigerators #3, 4 and 5 - sticky with food debris;* Flooring with food debris/spills - around the deep fat fryer, between cooking equipment and food service line and prep area counters;* Exterior of microwave - food debris on push button;* Ceiling pipes, ceiling light covers and airway ducts - significant accumulation of blowing dust;* Vent covers on service line - food spills/drips;* Rusty vent blowing air in refrigerator #5: * Shelf below sink/counter holding hot soup - food drips and spills; and* Fans and ceiling in walk in refrigerator had significant build up of dust. Improper food storage of the following: * Food storage container lids in dry storage were not securely closed (lentils, navy beans, split peas, sugar); * Cup stored in sugar container;* Food bins in baking area had scoops in brown sugar and panko crumbs;* Speed racks in walk in refrigerator had uncovered food - three trays of raw chicken and five trays of dessert; and * Speed rack in baking prep area - four pans of cobbler uncovered.b. Improper infection control practices: *Dishwashing staff not washing hands between dirty and clean tasks;* Service line staff not washing hands between glove changes;* Dishwashing staff not wearing hair restraint; and* Service staff entering kitchen beyond service line to dry food storage not wearing hair restraint. c. Other area of concern: *Ceiling lights without covers - entrance to kitchen, prep areas and in dishwashing area. The areas above were observed and discussed with Staff 1 (Executive Chef/Person In Charge) and discussed with Staff 2 (Health Center Administrator) and Staff 3 (Executive Director) on 06/11/24. The findings were acknowledged.

The findings of the kitchen inspection, conducted 06/01/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Services Food Sanitation Rules OARs 333-150-0000.
The findings of the re-visit to the kitchen inspection of 06/01/23, conducted 08/17/23, are documented in this report. It was determined the facility was in compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals, Oregon Health Service Food Sanitation Rules and OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview, and record review, 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 kitchen on 06/01/23 revealed the following areas needing cleaning and repair:* There was a puddle of standing water behind the commercial ovens and near electrical and plumbing fixtures;* A floor drain cover in front of the commercial ovens was broken and rusted; * A clogged floor drain underneath the two-compartment sink had standing water; * Walls, doors, and door frames throughout the kitchen had food splatters, scrapes and scuffs, black smudges, and areas where paint had chipped off;* Floors throughout the kitchen, including the walk-in cooler and freezer had buildup of food debris in corners, under equipment and around perimeter edges;* The shelving units in the walk-in cooler had areas of peeling coating and rusted metal;* A ceiling light fixture in the walk-in cooler was uncovered;* The windows above the dish machine had buildup of dirt, dust, and debris, did not have screens and were open during the kitchen inspection;* The baseboards in the dish washing area were damaged and peeling away from the wall;* The dry food storage area had black matter build up along the baseboards and the walls behind the storage shelves had areas of chipped and peeling paint;* The food storage bins containing flour and sugar had greasy/grimy lids and the plastic scoops were left in the bins;* A shelf under the food preparation table was covered with linoleum flooring and was noted to have buildup of dust and dried food debris;* The beverage station located in the dining room had chipped wood and paint on the cabinets, drawers, and baseboards; and* The commercial coffee maker located on the beverage station counter was leaking coffee and the counter and shelf below the coffee maker was damaged and heavily stained.During the observation of the food preparation and meal service it was identified the facility did not have alcohol wipes available to sanitize the thermometer after use. The need to maintain the kitchen clean and in good repair in accordance with the Food Sanitation Rules, OAR 333-150-000 was discussed with Staff 1 (Executive Director) and Staff 2 (Executive Chef ) on 06/01/23. They acknowledged the findings.

The findings of the re-licensure survey conducted 03/07/22 through 03/09/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.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 re-visit to the re-licensure survey of 03/09/2022, conducted on 05/26/2022, are documented in this report. It was determined the facility was in was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:a. On 03/07/22 at 2:30 pm and 03/08/22 at 11:00 am, the facility kitchen was observed to need cleaning and repair in the following areas:*Floors throughout the kitchen had black matter build-up, food debris, and grease in corners, under equipment, and around perimeter edges;*Baseboards throughout the kitchen and dry storage area had black accumulation along the top edges;*Interior and exterior of the three ovens had a buildup of grease and burnt food debris;*Pipes behind multiple appliances and above cooking areas had grease, dirt, and debris on them;*Ceiling and wall vents had an accumulation of lint and dust on the grates;*Debris on bottoms of drawers and cabinet shelves;*Top of dish machine, walls, pipes, gauges, and flooring behind/underneath the dish machine and sink had an accumulation of black matter, dirt, and debris;*Windows and window screens in the dish machine area had an accumulation of dust, debris, and cobwebs;*A storage closet that contained multiple kitchen supplies and cooking utensils needed to be cleaned and items stored appropriately; and*The service area counter and sink outside of the kitchen had food spills, splatters, and debris on the bottoms of drawers and cabinet shelves. b. The following areas needed repair:*Caulking in multiple areas throughout the kitchen, including the dish machine area;*Ceiling light covers missing in the dry food storage area, the walk-in refrigerator and freezer, and the dish machine area;*Kitchen doors and frames had chipped paint and gouges; and*Multiple areas had deteriorated grout and floor tiles throughout the kitchen.c. Kitchenette area: *Accumulation of dust and debris along the perimeter of baseboards;*Caulking behind the sink and between the counter and wall was dark brown; and*The cabinet under the sink had food spills and debris inside. The areas needing cleaning and repair were discussed and toured with Staff 1 (Executive Director) on 03/09/22. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs. Findings include, but are not limited to:During the re-licensure survey 03/07/22 through 03/09/22, there was a lack of scheduled and unscheduled activities provided for residents. During an interview on 03/09/22, Staff 2 (Assisted Living Administrator) provided the following information:The facility had an Activity Director assigned to the the independent living area of the facility but did not currently have an Activity Director assigned to the assisted living area and there was no current structured activity program or activity calendar in place for the assisted living residents. The facility was actively seeking to employ an Activity Director to assign to the assisted living facility and in the meantime caregiving and universal worker staff were providing some activities to residents but there was no documented evidence of those activities.The need to ensure the facility provided a daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs was discussed with Staff 1 (Executive Director) and Staff 2 on 03/09//22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated and resident specific interventions were determined, documented, communicated to staff, and monitored weekly through condition resolution for 2 of 3 sampled residents (#s 1 and 3) who experienced changes of condition related to falls. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 2019 with a diagnosis of hypertension.Review of Resident 3's clinical records including progress notes dated 01/01/22 through 03/06/22, incident reports, and service plans were reviewed during survey and indicated the resident experienced seven unwitnessed, non-injury falls.a. There was no documented evidence the facility determined resident specific fall prevention interventions when Resident 3 experienced unwitnessed, non-injury falls on the following dates:01/12/22, 01/15/22, 01/17/22, 01/31/22 and 02/01/22.b. On 01/18/22, Resident 3 experienced two unwitnessed, non-injury falls. The facility completed a "change in service plan" document which stated the facility implemented a "pad alarm and fall mat for safety" and two hour checks as fall prevention interventions. There was no documented evidence the facility monitored the effectiveness of the interventions.The need to ensure short-term changes of condition were evaluated and resident specific interventions were determined, documented, communicated to staff, and monitored weekly through condition resolution was discussed with Staff 2 (Assisted Living Administrator) on 03/09/22. She acknowledged the findings.
2. Resident 1 was admitted to the facility in 05/2021 with diagnoses including mild dementia and lower extremity edema. Resident 1's service plan noted he/she was a high risk for falls and instructed staff to assist with keeping pathways clutter free, and to report to nurse if staff observed the resident had difficulty with caring for pet cat, shortness of breath with walking, increased swelling of lower extremities that made it hard for him/her to walk, change in gait, ability to balance, change in level of consciousness, increased confusion and refusal to use adaptive equipment (wheelchair, walker) or if the resident fell. A review of the resident's record revealed he/she experienced a non-injury fall on 01/10/22 and a fall with injury on 01/23/22. There was no documented evidence interventions were monitored for effectiveness after each fall.The need to monitor the effectiveness of interventions for changes of condition was discussed with Staff 2 (Assisted Living Administrator) on 03/09/22. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure resident use pathway edges did not contain drop-offs. Findings include, but are not limited to:During a tour of the facility's exterior grounds on 03/08/22, the following observations were made:*Pathways in the back courtyard (leading toward the small pond) and near an entry/exit door had drop offs of up to four inches along the pathway edges creating a potential tripping risk to residents; and*The concrete near the back patio had an area that was chipped and cracked with pieces of concrete lifting up.The pathway drop-offs and patio concrete were shown to and discussed with Staff 1 (Executive Director) and Staff 2 (Assisted Living Administrator) on 03/08/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to:Observations of the facility on 03/08/22, showed the following areas in need of cleaning or repair:* The doors leading to the back courtyard, windowpanes in the activity room and overhead light fixtures in the back hallway and dining room had a build up cobwebs and insect debris;* The ceiling and wall in the corridor near the entrance to the assisted living area of the building had what appeared to be water leakage stains in the corner;* A wall near the washing machines in the laundry room had large holes in the drywall;* Flooring, in a clean linen storage room, had a buildup of black discoloring/stains around the front perimeter;* An overhead vent and surrounding ceiling in the dining room had a build up dust;* Flooring under the sink, in the shower room, was discolored with a black matter buildup on the tiles and grout and tiles appeared warped;* Two large overhead lights in the dining room did not have working light bulbs and/or were missing the light fixture covers;* A section of baseboard trim was missing from the wall in the hallway near the shower room; and* Doorframes to several resident rooms had areas of chipped and gouged paint.The areas in need of cleaning and repaired were shown to and discussed with Staff 1 (Executive Director) and Staff 2 (Assisted Living Administrator) on 03/08/22. They acknowledged the findings.