Regency Woodland

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

Based on observation, interview, and record review, it was determined the facility failed to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs and to meet the fire safety evacuation standards as required by the fire authority or the Department. Findings include, but are not limited to: The facility consisted of three distinct areas in a single one-story building that housed 27 residents at the time of the survey. Distinct area A housed 10 residents, area B housed 12 residents, and area C housed 5 residents. The current facility staffing plan and Acuity-Based Staffing Tool (ABST) were reviewed, and interviews with facility staff were conducted. The following was revealed: * Area A had two residents who required two-person assist; * Area B had one bed-bound resident who required two-person assist; * Area C had one bed-bound resident who required two-person assist; * During the acuity interview, the facility stated there was one resident in the facility who needed two to three persons to assist with transfers; and * According to the facility’s actual staffing plan, two direct care staff were scheduled to cover the night shift, leaving only one staff available to assist residents who required two-person assist while the other staff was on break. During an interview on 03/12/26 at 10:29 am, Staff 1 (ED) stated the facility’s night shift staffing policy was to instruct direct care staff not to leave the premises during breaks, therefore making the staff available in case any second person assist is needed. However, no written policy was available. The need to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs, and to meet the fire safety evacuation standards as required by the fire authority or the Department, was reviewed with Staff 1 and Staff 2 (Regional Director of Clinical Operations) on 03/12/26 at 10:48 am. They acknowledged the findings.

A written policy has been developed stating that night shift staff are not permitted to leave the building during their meal break. Due to the requirement to remain on-site, night staff will be paid for their meal break. If a meal break is interrupted for any reason related to resident care or operational needs, the meal break will be restarted once the interruption has been concluded. All night shift staff will be notified of the implemented policy and provided education on expectations regarding meal periods and on-site requirements. Supervisors will review the policy with staff and ensure understanding. Supervisors will monitor compliance through shift coverage checks and timekeeping reviews. Any violations of the policy will be addressed promptly through corrective action as appropriate. This policy will be reviewed annually.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

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

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: On 03/09/26, fire drill and fire and life safety records for the previous six months were requested. Review of the documentation provided revealed the following: * Staff were not evacuating or relocating residents during fire drills; therefore, the facility's fire drill documentation did not include information on escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, and number of occupants evacuated. The requirements regarding fire drills were discussed with Staff 4 (Maintenance) and Staff 1 (ED) on 03/11/26 at 1:24 pm. They acknowledged the findings.

The Executive Director has reviewed fire drill requirements with all department heads, emphasizing that residents must be evacuated or relocated during each fire drill to the extent consistent with safety and resident condition and alternating fire areas. • Maintenance manager will ensure that all future fire drills include resident evacuation or relocation. • Staff conducting fire drills are required to fully complete fire drill documentation, including escape routes used, number of occupants evacuated or relocated, encountered problems, start and end time of drill, and resident participation issues. The facility’s fire drill policy and documentation form was reviewed and it clearly outline required drill elements, including evacuation/relocation procedures and documentation expectations. • Fire drill documentation templates were reviewed to ensure mandatory fields for: • Start and End Time • Notification method • Escape route(s) used • Number of residents evacuated or relocated • Problems encountered • Resident resistance or non-participation The Executive Director or designee will review fire drill documentation after each drill for completeness and compliance with evacuation and documentation requirements. • Any identified deficiencies will be addressed promptly with additional staff education or corrective action as needed. A monthly review of documents will be preformed by the Executive Director and Maintenance Manager.

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

OAR 411-054-0090 (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 re-instructed, at least annually, on fire and life safety procedures according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 03/11/26 at 11:12 am. On 03/11/26 at 11:55 am, Staff 4 (Maintenance) was asked to explain the facility's process for re-instructing residents on fire and life safety procedures. Staff 4 reported he was responsible for providing fire and life safety training to all residents. However, the facility was unable to produce any documented evidence confirming the training had been given at least annually. The need for residents to be re-instructed on fire and life safety procedures at least annually, per the OFC, was discussed with Staff 4 and Staff 1 (ED) on 03/11/26 at 1:24 pm. They acknowledged the findings.

The Executive Director will initiate resident fire and life safety in-service to management on OAR 411-054-90 to ensure residents receive required education. • Residents have been provided instruction on fire and life safety procedures, including fire alarm response, evacuation routes, areas of refuge, and actions to take during a fire emergency. • Documentation will be reviewed to ensure resident instruction is recorded and retained. • A standardized annual fire and life safety education schedule has been implemented to ensure all residents receive instruction upon admission and at least annually thereafter. • A tracking log will be utilized to document resident participation, dates of instruction, topics covered, and any resident refusals or limitations. • The Executive Director will review resident fire and life safety instruction log to ensure annual instruction is completed and documented for all residents. • Any missed or incomplete instruction will be addressed promptly through re education and/ or corrective action. • Audits will be conducted the selected month(s) annual instruction is due by the Executive Director and or Maintance Manager.

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, conducted during a site visit on 08/06/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled residents (#1). Findings include, but are not limited to: A review of the facility's ABST indicated the following deficiencies: · Not evaluating all residents quarterly; and · Not accurately capturing care needs and time reflected in Resident 1's service plan. A review of the facility's ABST, including the last update dates, indicated 22 of 26 residents had not been evaluated quarterly. A review of Resident 1's service plan dated 07/23/25 indicated the following: · Staff were to monitor the resident for "signs and symptoms of hypoglycemia" and to take the resident's weight and blood pressure daily; · Staff were to escort the resident to and from activities up to 4x daily and to and from meals up to 3x daily when requested; and · Staff were to help brush the resident's hair daily in the am and pm. A review of Resident 1's ABST profile indicated 0 minutes for the following activities of daily living (ADLs): · Monitoring physical conditions and symptoms; · Ambulating or escorting the resident; and · Time spent assisting with grooming. An interview with Staff 1 (Registered Nurse) indicated the following: · Staff regularly monitored Resident 1 for physical conditions. Staff 1 had spent approximately half an hour observing the resident change his/her dressing for a skin wound on 08/06/25; · Staff escorted Resident 1 to and from meals and activities regularly. When staff see the resident leave his/her room, staff would assist by escorting. Staff also assisted when requested by Resident 1 via his/her call light. Staff 1 estimated that staff spent about 2 minutes at least 2-3 times per day escorting the resident; and · Resident 1 was independent with grooming and did not need assistance with hair brushing. Staff 1 indicated that brushing Resident 1's hair was on the daily task sheet, but did not believe that staff regularly, if ever, performed this task. The findings of the investigation were reviewed and acknowledged by Staff 1. The facility failed to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan, and the facility failed to update and document the ABST evaluation for each resident no less than quarterly.

Based on interview and record review, conducted during a site visit on 08/06/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled residents (#1). Findings include, but are not limited to: A review of the facility's ABST indicated the following deficiencies: · Not evaluating all residents quarterly; and · Not accurately capturing care needs and time reflected in Resident 1's service plan. A review of the facility's ABST, including the last update dates, indicated 22 of 26 residents had not been evaluated quarterly. A review of Resident 1's service plan dated 07/23/25 indicated the following: · Staff were to monitor the resident for "signs and symptoms of hypoglycemia" and to take the resident's weight and blood pressure daily; · Staff were to escort the resident to and from activities up to 4x daily and to and from meals up to 3x daily when requested; and · Staff were to help brush the resident's hair daily in the am and pm. A review of Resident 1's ABST profile indicated 0 minutes for the following activities of daily living (ADLs): · Monitoring physical conditions and symptoms; · Ambulating or escorting the resident; and · Time spent assisting with grooming. An interview with Staff 1 (Registered Nurse) indicated the following: · Staff regularly monitored Resident 1 for physical conditions. Staff 1 had spent approximately half an hour observing the resident change his/her dressing for a skin wound on 08/06/25; · Staff escorted Resident 1 to and from meals and activities regularly. When staff see the resident leave his/her room, staff would assist by escorting. Staff also assisted when requested by Resident 1 via his/her call light. Staff 1 estimated that staff spent about 2 minutes at least 2-3 times per day escorting the resident; and · Resident 1 was independent with grooming and did not need assistance with hair brushing. Staff 1 indicated that brushing Resident 1's hair was on the daily task sheet, but did not believe that staff regularly, if ever, performed this task. The findings of the investigation were reviewed and acknowledged by Staff 1. The facility failed to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan, and the facility failed to update and document the ABST evaluation for each resident no less than quarterly.

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure the quality of services rendered in the facility. Findings include, but are not limited to: 1. Situations were identified which constituted an immediate plan of correction to residents' health and safety in the following areas: * C160: OAR 411-054-0025 (4) Facility Administration: Operation; and * C303: OAR 411-054-0055 (1)(f-h) Treatment Orders. An Immediate plan of correction was requested on 06/12/24. The facility provided a plan of correction on 06/12/24 at 1:25 pm. The immediate risk was addressed, however the facility will need to evaluate the overall system failures associated with the licensing violation. 2. Refer to deficiencies in the report.

It was determined the facility failed to provide effective administrative oversight to ensure the quality of services rendered in the facility.   1. Actions related to specific residents are addressed with the corresponding tags. 2. Corrections and systems implemented will be addressed with the corresponding tags. 3. Corrections and systems implemented will be monitored through regular audits by the administrator/designees and/or consultants for a minimum period of 3 months. 4. Administrator will be responsible to see that the corrections are monitored and completed.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who required a modified diet texture. Resident 3 received inaccurate diet textures, placing him/her at risk for aspiration, choking and/or death. Findings include, but are not limited to: Resident 3 was admitted to the facility 02/2024 with diagnoses including stroke with left sided hemiplegia. Resident 3's clinical record was reviewed, interviews were conducted with staff and the resident, and observations were made. The following was identified: During the acuity interview on 06/10/24, Staff 2 (RN) indicated that no residents in the facility required a modified diet texture. Resident 3 had a signed physician order dated 02/16/24 for a mechanical soft diet texture. The resident was admitted to the facility seven days later, on 02/23/24. The resident's 30-day evaluation, dated 03/21/24, and quarterly evaluation, dated 06/06/24, stated the resident required a mechanical soft diet texture. The resident's lunch was observed being prepared and plated by Staff 16 (Cook) on 06/11/24 at 12:50 pm. He stated the kitchen staff were not aware of any modifications that needed to be made when preparing or plating food for Resident 3. The meal consisted of a 2 inch by 2 inch brownie, spaghetti and red sauce with noodles up to 1 1/2 inches long, ground beef chunks up to 3/4 inch in size, and a whole dinner roll. Prior to the meal being served to the resident, on 6/11/24 at 12:52 pm, Staff 1 (Executive Director) and Staff 2 were asked by the survey team whether the meal appeared appropriately plated for a resident with an order for a mechanical soft diet texture. Staff 1 stated that the facility did not provide meals with a mechanical soft diet texture. Resident 3 was observed with the meal. The resident was served while lying in bed in his/her room. The head of the bed was elevated approximately 30 degrees, and the resident had slid down the bed, so that when the meal was placed onto the over-bed tray table, the resident was unable to see over the top of the plate. During the 50 minutes s/he was observed, the resident attempted to eat only his/her brownie. The resident was observed to have difficulty feeding him/herself including difficulty coordinating lip and tongue movement in order to get food into his/her mouth, and difficulty keeping food in his/her mouth while swallowing. Approximately 30% of the food the resident attempted to eat ended up on his/her shirt. The resident was observed making coughing and hacking sounds twice during the time s/he was observed. The resident attempted to drink from his/her straw cup and demonstrated difficulty closing his/her lips around the straw and greater than 50% of the liquid spilled out the left side of his/her mouth when attempting to swallow. During an interview on 06/11/24 at 1:58 pm, Staff 14 (MT) and Staff 18 (MT) stated the resident had difficulty swallowing and needed his/her medications administered in pudding in order to swallow them safely. These observations and interviews were reviewed with Staff 1 and Staff 2 on 06/11/24 at 3:20 pm. They stated that none of the cooking staff were trained in how to prepare a mechanical soft diet texture. During this interview, they stated they would make sure the resident received the correct diet texture at dinner and all meals moving forward. At 3:56 pm, Staff 1 provided the survey team with the information that had been used to educate cooking staff which included a short handout and a video which described how to modify meat textures, but did not describe the other components of mechanical soft diet texture. There was no documentation of any education provided to care staff or updates made to the resident's service plan. Staff 1 and Staff 2 stated that for dinner the resident would be served refried beans and Spanish rice with ice cream for dessert. They stated the resident requested the main menu item which was a chicken quesadilla, but they told him/her they could not modify this for his/her diet texture needs. At 5:10 pm on 06/11/24, the resident was served a bowl of refried beans, Spanish rice with no sauce or gravy, and ice cream. The resident again demonstrated difficulty getting food to his/her mouth and keeping food in his/her mouth when attempting to swallow, with approximately 30% of the food s/he attempted to eat ending up on his/her face and shirt. The resident ate three bites of beans, two bites of rice, and a small bowl of ice cream. The resident coughed and spit out food one time, which occurred while attempting to eat a bite of the rice. On 06/12/24 at 10:43 am, an immediate plan of correction was requested to address the increased risk for choking and/or death due to modified diet texture orders not being followed and the resident's difficulty eating independently. The facility provided a plan of correction on 06/12/24, prior to survey exit. The immediate risk was addressed, however the facility will need to evaluate the overall system failures associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 and Staff 2 on 06/11/24 through 06/14/24. They acknowledged the findings. The above findings were reported to APS by the survey team on 06/21/24 at 1:21 pm.

It was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who required a modified diet texture. Resident 3 received inaccurate diet textures, placing him/her at risk for aspiration, choking and/or death. 1. Resident 3 expressed preference for a regular diet and prefers to eat in her room. She was re-evaluated by her provider and approved for regular diet, thin liquids with a new diet order in place. Service Plan to be updated and staff educated on diet and proper supervision and positioning for meals. 2. All resident diet orders were reviewed, no other residents have modified diet textures. RN, dietary and care staff educated on resident diets and importance of following diet orders. Larger board installed for dietary staff to track dietary needs for individual residents and to ensure food prepared for each resident is appropriate and matches dietary orders. 3. Administrator or designee will randomly audit resident meals for diet order accuracy for a period of 3 months. 4. Administrator will be responsible to see that the corrections are monitored and completed.

Based on interview and record review, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to: A group interview was conducted with nine of the 28 residents residing at the facility on 06/11/24. During the group interview, residents stated very few activities occurred during the week, and no activities occurred on weekends. Multiple residents stated they were "always bored" and "lonely". During an interview with Staff 6 (Activities) on 06/13/24 at 2:05 pm, she stated that she was in the facility assisting with activities three days per week, and she assisted with other duties including setting up medical appointments and driving the facility bus on her other scheduled work days. She stated four days per week, residents were responsible for leading all activities. Upon review of the activities calendar for the week of 06/09/24 through 06/15/24, 23 activities were scheduled. Of these activities, 13 were designated "resident-led". Staff 6 described that this meant the resident's were responsible for setting up and leading the activity, and no staff member would be present to ensure the activity occurred or assist the residents with activity set-up. The need to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents was reviewed with Staff 1 (Executive Director) 06/14/24 at 11:30 am. She acknowledged the findings.

It was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. 1. All residents have the potential to be negatively impacted by a lack of daily activities based on resident group and individual interests. Ensuring daily staff-led activities are taking place will benefit all residents. 2. Activity Director was educated on expectation that there are daily staff led activities to meet resident needs based on group and individual interests as determined by resident social histories. Activity calendar to be updated to reflect changes. 3. Administrator and/or designee will monitor and keep a log of daily activities to verify calendar is being followed and activities are staff led. 4.  Administrator will be responsible to see that the corrections are monitored and completed.

Based on observations, interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and/or failed to ensure signed physician or other legally recognized practitioner orders were documented for all medications and treatments the facility was responsible for administering for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Resident 3 did not receive the correct diet as ordered by his/her physician, placing him/her at significant risk of aspiration, choking and/or death. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 02/2024 with diagnoses including stroke with left sided hemiplegia. a. The resident had a signed physician order for mechanical soft diet texture dated 02/16/24. The resident was observed being provided a meal which did not adhere to mechanical soft diet texture on 06/11/24. On 06/11/24 at 12:52 pm, Staff 1 (Executive Director) stated that the facility did not provide meals with a mechanical soft diet texture. While attempting to eat on 06/11/24, the resident was observed to have difficulty feeding him/herself including difficulty coordinating lip and tongue movement in order to get food into his/her mouth, and difficulty keeping food in his/her mouth while swallowing. The resident was observed making coughing and hacking sounds twice while attempting to eat the meal which did not adhere to physician's orders. On 06/12/24, an an immediate plan of correction was requested. The facility provided a plan of correction on 06/12/24 at 1:25 pm. The immediate risk was addressed, however, the facility will need to evaluate the overall system failures associated with the licensing violation. Refer to C160. b. The resident's MARs, dated 05/01/24 through 06/10/24, and physician orders were reviewed. There was no documentation that the facility had a signed order for the following medications which were listed on Resident 3's MAR: * PRN glycerin suppository (for constipation); * PRN Mylanta, 30 ml by mouth every four hours (for gastrointestinal upset); and * PRN acetaminophen 500 mg, 1 tablet by mouth every four hours (for pain or fever). The need to ensure all orders were carried out as prescribed, and signed physician or other legally recognized practitioner orders were documented for all medications and treatment's the facility was responsible to administer was reviewed with Staff 1 and Staff 2 (Wellness Director/RN) on 06/11/24 through 06/14/24.  They acknowledged the findings. 2. Resident 2 was admitted to the facility in 05/2024 with diagnoses including dementia, COPD and hypertension. Resident 2's MARs, dated 05/26/24 through 06/10/24, and all physician's orders were reviewed. On 06/08/24, the facility made the following changes to Resident 2's MAR: * Added PRN tramadol 50 mg (for pain); and * Discontinued daily cholecalciferol (for Vitamin D deficiency). There was no documented evidence the facility had a signed physician's order for the above changes. The resident was administered PRN tramadol four times between 06/08/24 and 06/10/24. During an interview with Staff 2 (Wellness Director/RN) on 06/12/24 at 3:21 pm, she stated the facility had made changes to the MAR based on an after-visit summary which was not signed by a physician. The need to ensure all orders were carried out as prescribed, and signed physician or other legally recognized practitioner orders were documented for all medications the facility was responsible to provide, was reviewed with Staff 1 (Executive Director) on 06/14/24 at 11:30 am. She acknowledged the findings. 3. Resident 1 was admitted to the facility in 11/2021 with diagnoses including heart failure and dementia. Resident 1's MAR and signed physician's orders were reviewed. A signed physician order, dated 05/20/24, indicated the resident was to receive Sertraline 25mg at bedtime for depression. Record review indicated the facility failed to transcribe the medication to the MAR and had not been administering the medication. During an interview on 06/14/24, Staff 2 (Wellness Director/RN) reported the facility had missed the order and Resident 1 had not been receiving the medication. On 06/14/24, the need to ensure all medications and treatments were being administered as prescribed was discussed with Staff 1 (Executive Director) and Staff 2. They acknowledged the findings.

It was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and/or failed to ensure signed physician or other legally recognized practitioner orders were documented for all medications and treatments the facility was responsible for administering for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Resident 3 did not receive the correct diet as ordered by his/her physician, placing him/her at significant risk of aspiration, choking and/or death. 1. Resident 3 expressed preference for a regular diet and prefers to eat in her room. She was re-evaluated by her provider and approved for regular diet, thin liquids with a new diet order in place. Service Plan to be updated and staff educated on diet and proper supervision and positioning for meals. 2. All resident diet orders were reviewed for accuracy. RN, dietary and care staff educated on resident diets and importance of following diet orders. Larger board purchased for dietary staff to track dietary needs for individual residents and ensure food prepared for each resident is appropriate and matches orders. Medication and treatment recap to be completed for every resident to ensure accuracy of all orders. Staff to be re-educated on Triple check process to ensure accuracy of new orders. 3. Admin or designee will monitor completion of medication and treatment recaps and perform weekly audits of a representative sample of new resident orders for accuracy for 3 months. 4. Administrator will be responsible to see that the corrections are monitored and completed.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 long-term direct care staff (#s 8, 9, 11 and 14) completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care (CBC) setting, including six hours related to dementia care. Findings include, but are not limited to: Staff training records were reviewed on 06/13/24 and 06/14/24. Staff 8 (CG), hired 08/13/21, Staff 9 (CG), hired 04/12/22, Staff 11 (CG), hired 08/14/21, and Staff 14 (MT), hired 02/21/22, lacked documented evidence of completing a minimum of 12 hours of in-service training annually, based on date of hire, including six hours related to dementia care. The need to ensure all direct care staff complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a CBC, including six hours related to dementia care, was discussed with Staff 1 (Executive Director and Staff 3 (Business Office Manager) on 06/14/24 at 11:00 am and 11:30 am, respectively. They acknowledged the findings.

It was determined the facility failed to ensure 4 of 4 long-term direct care staff (#s 8, 9, 11 and 14) completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care (CBC) setting, including six hours related to dementia care. 1. All residents have the potential to be negatively impacted when staff are not properly trained. 2. Business Office created a matrix to track staff compliance with training requirements. Staff will be removed from the schedule when they fail to meet training requirements. 3. Administrator or designee will audit 3 staff files weekly for training compliance. 4. Administrator will be responsible to see that the corrections are monitored and completed.

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 and annually. Findings include, but are not limited to: On 06/10/24 and 06/11/24, facility fire and life safety records were reviewed and lacked documented evidence the following required elements were completed: *Instruction to Resident 2 on fire/life safety procedures within 24 hours of admission; and *A written record, including content, of annual instruction to Resident's 1 and 4 on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire. During a group interview on 06/11/24 at 2:00 pm, eight unsampled residents indicated they had not been instructed annually on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire. On 06/14/24 at approximately 12:00 pm, the need to ensure residents were provided instruction per the Oregon Fire Code was discussed with Staff 1 (Executive Director). She acknowledged the findings.

It was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually. 1. Lack of timely fire and life safety training puts all residents at risk, timely training will enhance resident safety. 2. Current residents will receive fire and life safety instructions. New residents will receive fire and life safety training as part of the admission process and included on the admission checklist. Business Office Manager will maintain a calendar to track when the training is due for each resident. Annual training will be completed prior to each resident's move-in anniversary. 3. Administrator or designee will audit all resident charts to verify completion of fire and life safety training. Administrator or designee will verify new residents received training and audit 3 resident charts weekly for 3 months to verify ongoing compliance.

The findings of the re-licensure survey, conducted 06/10/24 through 06/14/24, 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 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 A situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause a resident serious harm. An Immediate Plan of Correction was requested in the following areas: OAR 411-054-0025 (4) Facility Administration: Operation; and OAR 411-054-0055 (1)(f-h) Treatment Orders. The facility put an Immediate Plan of Correction in place during the survey.

The findings of the first re-visit to the re-licensure survey of 06/14/24, conducted on 10/14/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, conducted during a site visit on 05/22/24, it was confirmed the facility failed to implement a service plan that reflects the resident's needs for 1 of 2 sampled residents (#1). Findings include, but are not limited to: During an interview on 05/22/24, Staff 1 (ED) indicated s/he was aware the behavioral service plan wanted the staff to check on Resident 1 every two hours. Staff 1 indicated the facility does not always check on Resident 1 every two hours due to increasing his/her behaviors. Witness 1 indicated in the complaint on 12/07/23, the facility was not complying with Resident 1's behavioral service plan. Staff 1 indicated to Witness 1 the facility does not need to be checking on Resident 1 every two hours and that s/he needed to be in a behavioral/special needs facility. A review of Resident 1's behavioral service plan dated 09/05/23, indicated staff are expected to "check in" on resident 1 at least every two hours to ensure needs are met to prevent behaviors. A review of Resident 1's quarterly evaluation dated 02/28/24 and service plan dated 02/20/24 had not indicated staff were to check on Resident 1 every two hours. It was confirmed the facility failed to implement a service plan that reflects the resident's needs. On 05/22/24, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The facility will change Resident 1's service plan to match his/her behavioral service plan.

Based on observation, record review, and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen and dining room beverage service, food  storage, preparation areas and service  on 01/11/24 revealed splatters, spills, drips, dust and debris noted on: - Interior of cabinets, drawers; - Walls under ware washing machine; - Interior of microwave; - Open stainless steel shelving throughout kitchen; - Fan blades and cage; - Metal storage racks throughout kitchen; - Ovens; - Interior of refrigerators and freezers; - Utility room walls and floors; - Floors under major appliances; - Windows and portable AC unit behind microwave; and - Canned goods in dry storage room. The following areas/items were found needing repair: - Reach in refrigerators in kitchen not registering 41 degrees; - Ware washing machine wash cycle temperature gauge not registering 150 degrees; - Ware washing machine rinse cycle temperature gauge not consistently registering 180 degrees; - Freezer with evidence of temperature irregularity and damaged seal; and - Multiple small holes around pipes or conduit were found. Areas needing sealing to prevent entry points for possible pests. * Dining room beverage area found with areas of chipped paint and cabinetry in disrepair. * Main kitchen cabinetry with interior and exterior areas of exposed wood edges resulting in a surface that is not smooth or cleanable. Hinges on multiple cabinets were not operating correctly. Many shelves in cabinets/cupboards with damage and not smooth, cleanable surfaces. * Dry storage room door was unsecured for several hours. Door opened to resident care area hallway where entry by non-kitchen/authorized staff could occur. * Multiple cutting boards were found with deep scoring and staining. * Multiple sauté pans were found with deep scoring and flaking of non-stick surface material. * Multiple items in refrigerators/freezers were not covered and/or dated when prepared or opened. Mayonnaise container was found expired. * Items in freezer not stored to allow for adequate air circulation. Multiple items were found with visible signs of freezer burn. * Multiple items in dry storage were observed not securely sealed and/or not labeled and/or not dated. Multiple items were found expired and/or removed from manufacturer packaging without labeling or date marking. Several dry goods bins were found with lids ajar and scoops left in food product. * Ware washing machine was found below 150 degrees during multiple wash cycles between 10:15 am and 11:15 am. Ware washing machine was found below 180 degrees during multiple rinse cycles between 10:15 am and 11:15 am * Multiple kitchen staff found without hair or facial hair restrained as required. Staff 2 (Dietary Services Director) and the surveyors toured the kitchen. Staff 2 acknowledged the above findings. At approximately 2:00 pm, the above areas in need of cleaning, repair and attention were reviewed with Staff 1 (Executive Director). S/he acknowledged the findings.

1)Interior of cabinets, drawers, walls under and around washing machine, interior of microwave, open stainless steel shelving, the fan blades and cage, metal storage racks, the right side oven interior, the interior of the refrigerators and freezers, the utility room walls and floors, the floors under the major appliances, the windows and portable AC units and the canned goods in the dry storage room will be deep cleaned. 2) A cleaning schedule will be put in place for daily, weekly, and monthly cleaning. 3) Weekly meetings with the ED and the kitchen manager will review the cleaing schedule and the kitchen manager will do a daily walk through to ensure complaince with the schedule. 4)The kitchen manager will be responsible for the oversight of the cleaning with reports to the ED for compliance. 1)Reach in refrigerator not registering at 41degrees was services by a technician and found to not have the fan turned on. Fan was turned on on 1/12/2024. 2) Staff educated on which buttons on refrigerator need to be turned on at all times and temp logs for refrigerators in place. 3). Temp logs reviewed by kitchen staff daily and any inconsistancies will be reported to kitchen manager. 4) Temp logs maintained and reviewed daily for compliance by the kitchen manager and reported to the ED during the weekly meeting. 1).Ware washing machine was services by Ecolab 1/12/24 and shown to be maintaining 150 and 180. 2).Temp logs in place to monitor the machine temps two times per shift.Staff educated to only run machine when the temps register at 150 and 180. 3) Temp logs will be reviewed by kitchen staff daily and any inconsistanceis will be reported to kitchen manager 4)Temp logs maintained and reviewed weekly for complinace by the kitchen manager and reported to the ED during weekly meeting. 1)The freezer with damaged seal and and evidence of temperature irregularity was emptied and will be disposed of. 2). Freezer room added to weekly maintenance and ED building walk through.and to the kitchen cleaning schedule. Any concerns will be reported to the kitchen manager. 3).Maintenance Weekly walk through to identify needed repairs 4).Kitchen manager will be maintaining the cleaning schedule where issues can be identified and repairts to be done by maintenance. 1)Small holes identified around pipes were sealed on 1/23/24. 2)Weekly ED and maintance walkthrough to identify repair needs. 3). Weekly walkthroughs 4). Maintenace Manager will be responsible for repairs and monitoring for effectiveness. 1). Cabinets in the dining room and the kitchen identified to have chips and uncleanable surfaces and hinges that need  repair will be repaired to be smooth, cleanable, and functionable state. 2).Cabinet surfaces will be added to the ED and Maintenance manager walkthrough for observation 3).Weekly during the walkthrough 4). The maintenance manager will be responsible for making sure the itegrity of the cabinets is maintained and during the weekly ED and Maintenace meeting this will be discussed. 1). Signage was placed on the dry storage door that that door is to remail closed and locked at all times. Kitchen staff educated on the necessity of keeping this door closed and locked at all times. 2). Management team also educated on the door needing to be closed and locked. Any violations to be reported to the kitchen manager. The kitchen manager will be including this door on his daily walk through for compliance. 3). Daily and weekly 4).The kithcen manager is responsible for making sure the staff are closing this door during and after use. 1)Cutting boards and pans that had deep scoring and staining were disposed of. 2). New cutting boards and pans were purchased. Staff educated on using non-metal tools on the non-stick pans and when to report to kitchen manager the need for replacing them. 3).The kitchen staff to report any concerns with deep cuts and scratches and condition of equipment will be added to the weekly walkthrough for the kitchen manager. 4). The Kitchen manager is respsonsible for making sure the equipment is in good working order. 1) Items found to be opened and not dated, expired, soiled, or freezer burned were disposed of. 2).Kitchen staff to be educated on FIFO principles and how to properly date and store opened food. 3). The weekly walkthrough for the kitchen will include auditing the dry storage, freezers, and refrigerators for properly labeled food and expired food. 4)The kitchen manager is responsible for ensuring all food products are properly stored. 1). Kitchen staff not wearing hair/beard nets or head coverings - Beard and hair nets were purchased. Staff given the opportunity to wear a hat. 2). The kitchen manager will lead by example and ensure that all staff wear the approporiate head and face gear. Staff training on the necessity of wearing hair covering items. 3)The Kitchen manager will ensure the staff is following this directive daily. 4). The kitchen manager and the ED are responsible for making sure the staff are complying with hair covering as required.

The findings of the kitchen inspection, conducted 01/11/24, 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 01/11/24, conducted 05/16/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review, conducted during a site visit on 09/27/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of Resident 1's Incident report, November 2021 and "Medication Form" dated 11/19/21 stated: "Resident 1 missed [his/her] 2 doses of Lorazepam on 11/19/21 however did receive 3rd does for the day.  Medication was not ordered in a timely manner.  Medication was sent from pharmacy STAT and a delivery driver brought it to the facility.  New process for Narcotic is re-order date will be circled on the card.  When the medication is punched the Med Tech will re-order.  This should be when there is a seven-day supply left of the medication.   Med Techs will be in-serviced and RCC to conduct weekly med cart audits to assure new process is followed.  Abuse and neglect were ruled out." During an interview, Staff 1 (ED) confirmed s/he Staff 1 had not worked at the facility during the time of incident. The findings were reviewed with and acknowledged by Staff 1 (ED) on 09/27/23. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal plan of correction: New process for Narcotic is re-order date will be circled on the card.  When the medication is punched the Med Tech will re-order.  This should be when there is a seven-day supply left of the medication.   Med Techs will be in-serviced and RCC to conduct weekly med cart audits to assure new process is followed.

The findings of the on-site investigation conducted 09/27/2023 are documented in this report. The investigation 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. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:                        Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on interview and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include: Record review on 8/2/2022 of timecards for 6/16/2022-6/30/2022, posted staffing plan, ODHS ABST, and service plans for Resident #1-2 (R1 and R2). The posted staffing plan is not reflective of the ABST as it has not been fully implemented yet. Call light logs from 6/25/2022-6/30/2022 revealed multiple call light response times ranging from 25 minutes to 1 hour and 39 minutes. Both R1 and R2 indicate on the facilities ABST that these residents need 0 minutes for call light response time, reviewing them it indicates R1 pushed their button 26 times while R2 pushed it 33 times. In an interview on 8/2/2022 Staff #1 (S1) stated that they are using the ODHS ABST, however, they were not aware that it generated a staffing plan based on amount of caregiving time indicated with the tool. The above information was shared with S1 on 8/2/2022. Plan of Correction: The facility will speak with Policy Analyst (PA) to get further clarification on how to generate the staffing plan to they are in compliance with the ODHS ABST.