Evergreen Memory Care Community

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

Based on interview and record review, it was determined the facility failed to ensure the resident’s move-in evaluation addressed all required elements for 1 of 1 sampled resident (#4) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 11/2025 with diagnoses including mild cognitive impairment of uncertain or unknown etiology, Type 1 diabetes with hyperglycemia, and unspecified dementia mild with psychotic disturbance. The initial evaluation, dated 11/25/25 failed to address the following elements: * Gender identity; * Hobbies, social interests, and leisure activities; * Traditions; * Mental health issues, including history of treatment and effective non-drug interventions; and * Review of risk indicators, including complex medication regimen, history of dehydration, recent losses, and unsuccessful prior placements. The need to ensure the move-in evaluation addressed all required elements was reviewed with Staff 1 (Administrator) and Staff 2 (Wellness Director, LPN) on 01/14/26 at 1:30 pm. They acknowledged the information.

Evergreen Memory Care will ensure move-in, 30-day, quarterly and as needed evaluations address all required elements. Moving forward, all admissions will have a completed Resident Evaluation to address all required elements. Resident #4's evaluation will be updated to address all required elements. Weekly audits will be completed by ED and HSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. ED and RSD will be responsible.

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

OAR 411-054-0036 (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.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident’s current status and care needs, provided clear direction to staff regarding the delivery of services, and were implemented for 1 of 4 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2025 with diagnoses including dementia. The resident's clinical record from 10/05/25 through 01/12/26 was reviewed, and interviews were completed with staff. Observations made throughout the survey identified the following: a. The service plan, dated 11/06/25, was not reflective of the resident’s current status and/or care needs and lacked clear direction to staff in the following areas: * Fall interventions; * Assistance with transfers; and * Assistance with mobility. b. The service plan was not implemented in the following areas: * Assisting with hearing aids; and * Fall interventions, including using a wheelchair, bed alarm, chair alarm, and cleaning out cups from his/her room. The need to ensure service plans were reflective of the resident's care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (LPN), Staff 3 (RN), and Staff 4 (RCC) on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will ensure all residents' service plans are reflective of residents' current care need and preferences and provides clear direction regarding the delivery of services. All resident service plans will be updated and updated as needed to include resident changes. These updates will be written to provide clear direction to team members regarding the delivery of services. Service plan for Resident #2 will be updated to reflect residents' current care needs and preferences and will provide clear direction regarding the delivery of services. A "Service Plan Update" form will be used to update a service plan as needed. Weekly audits will be completed by ED and HSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. All Staff Meeting will be held February 10, 2026 with topic to include service plans. ED, HSD and RN will be responsible.

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.

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.

Based on observation, interview, and record review it was determined the facility failed to determine actions or interventions needed following changes of condition, communicate the actions or interventions to staff on each shift, ensure staff instructions or interventions were resident-specific and made part of the resident record, with weekly progress noted until the condition resolved, and ensure the interventions were monitored for effectiveness for 1 of 3 sampled residents (# 2). Resident 2 experienced falls with injuries. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2025 with diagnoses including dementia. During the entrance conference interview on 01/12/26, staff identified the resident had a history of falls. The service plan, dated 11/06/25, and subsequent interim service plans (ISP’s) and progress notes, dated 10/02/25 through 01/10/26, were reviewed. Interviews with staff and observations were conducted during the survey. On 01/12/26 at 12:30 pm, Resident 2 presented with full bilateral facial bruising and a laceration on his/her skull, approximately two-three inches in length, with metal sutures closing the laceration. Resident 2 was observed using a walker during the survey. Resident 2’s service plan and ISP’s from 10/28/25 through 01/10/26, instructed staff of the following fall interventions: * Offer help when s/he was moving furniture; * Non-skid strips next to bed; * Ensure s/he was wearing non-skid socks or shoes at all times; * Staff to clean out any cups from his/her room promptly (ISP 11/25/25); * Keep alarm pad in resident’s bed (“Permanent Change in Service Plan” 12/31/25); and * Take resident to the bathroom upon waking up, after meals, between lunch and dinner and before bed (“Permanent Change in Service Plan” 01/08/26). a. The resident had the following falls that lacked monitoring of fall interventions for effectiveness and/or communicating the change of condition and interventions to staff on each shift: * 09/30/25 – Unwitnessed fall with injury to the left “small toe.” There was an incident report form completed with a fall intervention to encourage resident to not wear silk night gowns. During an interview on 01/13/26 at 2:51 pm with Staff 1 (Administrator), Staff 2 (Wellness Director, LPN), and Staff 4 (RCC) it was confirmed direct care staff didn’t have access to the incident reports to be informed of the new fall intervention. Staff confirmed their system to notify staff of changes in condition, including fall interventions, was to communicate the changes using an ISP or Permanent Change in Service Plan form. * 10/28/25 - Unwitnessed non-injury fall; and * 10/28/25 - Second unwitnessed fall with abrasion to the right elbow. There was no documented evidence the previous fall interventions were monitored for effectiveness or new interventions were put in place following the two falls on 10/28/25. * 11/25/25 - Unwitnessed fall. Resident stated s/he hit his/her head. There was an ISP instructing staff to clean out any cups from his/her room promptly. Observations on 01/12/26 at 12:30 pm and on 01/14/26 at 9:00 am showed the fall intervention to remove cups with liquids in them on the resident’s table near the bed was not followed. * 12/02/25 - Unwitnessed fall with abrasion to left upper arm. An intervention to place bright tape on the door threshold between the resident's apartment and bathroom was noted on an incident report. There was no documented evidence the intervention, including instructions on who to notify if the tape became dislodged from the threshold, was communicated to staff. * 12/20/25 - Unwitnessed non-injury fall. The incident report noted an intervention: “will collect a UA [Urinalysis].” There was no documented evidence the intervention was communicated to staff, and there was no documented evidence the UA was collected. * 12/25/25 - Unwitnessed fall with abrasion to right forearm. On 12/31/25 (six days later) there was a “Permanent Change in Service Plan” which instructed staff to keep alarm pad in resident’s bed. During an interview on 01/12/26 at 2:30 pm, Staff 7 (Health Services Staff/CG) reported, “I think [s/he] has a bed alarm, but I think it’s only for night-time.” Observations on 01/12/26 through 01/14/26 showed there was not an alarm on the resident’s bed. There was no documented evidence the facility monitored the fall interventions for effectiveness. Resident 2 continued to have the following injury falls, which resulted in emergent medical care from paramedics and/or emergency room visit. * On 01/02/26 Resident 2 experienced another unwitnessed fall with pain to the left hip. * 01/06/26 - Unwitnessed fall with head injury resulting in an emergency room visit and multiple sutures in the resident’s head. An incident report dated 01/06/26 through 01/08/26 had the following description of the incident: “There was water on the floor from a cup that was spilt over ... there was a wheelchair pushed against dresser and [his/her] head was under the wheelchair ... there was blood on the floor and coming from the back of residents [SIC] head.” Staff called 911, and the resident was transported to the hospital. The incident report further noted a “pressure alarm will be used in [his/her] chair in [his/her] room as well as [his/her] bed.” The intervention to use a pressure alarm on his/her chair was not communicated to staff and, based on observations from 01/12/26 through 01/14/26, wasn’t being implemented. There was no documented evidence the facility determined actions or interventions needed to prevent further falls, communicated the use of a wheelchair or chair alarm to staff, or monitored any of the fall interventions to ensure they were being implemented and were effective. This resulted in pain, physical injury, a major deviation in the resident’s health and functional ability, and the resident continued to have two more falls with injuries on the following dates: * 01/10/26 - Unwitnessed fall with bruise to the forehead, bleeding on the front top part of head and was complaining of pain in his/her left hip. The resident was administered a pain medication. * 01/10/26 - Unwitnessed fall with injury to forehead and skin tear to the left elbow. An incident report was completed on 01/12/26 that read: “will ask hospice for a wheelchair.” The incident report from 01/06/26 noted the resident already had a wheelchair in their room, and the use of a pressure alarm on chairs was an intervention that should have already been in use. There was an ISP written on 01/10/26 instructing staff to monitor for pain and latent injuries. However, there was no documented evidence the facility communicated the use of a wheelchair or chair alarm to staff or monitored any of the previous fall interventions to ensure they were being implemented and were effective following the two falls on 01/10/26. There was no documented evidence the facility determined actions or interventions needed to prevent falls, communicated the actions or fall interventions to staff, or monitored any of the fall interventions to ensure they were being implemented and were effective. This resulted in pain, physical injury, and a major deviation in the resident’s health and functional ability. The need to ensure the facility communicated changes of condition to staff on each shift, ensure staff instructions or interventions were resident-specific and made part of the resident record, and ensure the interventions were monitored for effectiveness and were being implemented was discussed with Staff 1 (Administrator), Staff 2 (LPN), and Staff 4 (RCC) on 01/13/26 at 2:51 pm and with Staff 3 (RN) on 01/14/26 at 3:14 pm. They acknowledged the findings. b. The following short-term changes of condition were not monitored through resolution: * 01/05/26 - Cephalexin 250 mg capsule (antibiotic for urinary tract infection), give one capsule by mouth three times per day for five days (total of 15 capsules). The resident was administered 10 doses of the antibiotic. An observation of the medication cart on 01/14/26 at 11:40 am showed there were three capsules remaining in the bottle. A progress note dated 01/06/26 indicated the condition was resolved by Staff 2 (Wellness Director/LPN) prior to the resident completing the medication. The facility failed to monitor the resident to determine the efficacy of the medication in treating the resident’s condition. The need to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on all shifts and that changes were monitored, with progress noted at least weekly until the condition resolved, was discussed with Staff 1 (Administrator), Staff 2 (LPN), and Staff 4 (RCC) on 01/13/26 at 2:51 pm and with Staff 3 (RN) on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will ensure that residents' short term and long term change of conditions are monitored appropriately. Community will determine actions/interventions needed, communicate actions or interventions to team members on all shifts, and monitor changes through resolution with weekly documentation. Resident #2's significant change of condition assessment by RN was completed on January 12, 2026. RN assessments will be completed when applicable. Routine clinical meetings will be held at minimum 5 days/week with ED, HSD and RN. These meetings are a double check to review and identify resident short term and long term change of conditions. Weekly high risk resident meetings will take place to assure compliance. All staff in-service will be held on February 10, 2026. Training topics to include residents' short term and long term change of conditions. ED and HSD will be responsible

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.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

Based on observation, interview, and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed and that the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for all medications that the facility was responsible to administer for 1 of 1 sampled resident (#2) who was administered medications. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2025 with diagnoses including dementia. The resident’s physician orders, dated 01/11/26, and the 01/01/26 through 01/14/26 MAR were reviewed and identified the following: * Hydrocodone/APAP 5mg/325mg (a controlled substance to manage pain) was administered 13 times without a written order from the prescriber. * Furosemide 20 mg tablet, give two tablets (40 mg total) every day was not administered on 01/11/26 and 01/12/26 because the medication was not available. During an interview and observation on 01/14/26 at 11:40 am with Staff 12 (Health Services Staff/MT), it was confirmed the medication was not available on those dates. The date received on the new medication card confirmed the medication was received on 01/12/26 and the resident began receiving the Furosemide again on 01/13/26. * Cephalexin 250 mg capsule (antibiotic for urinary tract infection) give one capsule by mouth three times per day for five days (total of 15 capsules or doses). The resident was administered 10 doses of the antibiotic. An observation of the medication cart on 01/14/26 at 11:40 am showed there were three capsules remaining in the bottle. The need to ensure medication orders were carried out as prescribed and that the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for all medications that the facility was responsible to administer was discussed with Staff 1 (Administrator), Staff 2 (LPN), Staff 3 (RN), and Staff 4 (RCC) on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will ensure Treatment Administration Records (TARs) will be accurate. Daily audits will be completed by HSD, or Designee to be in compliance. Audits will be reviewed in monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. All staff in-service to be held on Febuary 10, 2026. Training topics to include accuracy of TARs. ED, HSD, charge nurse and/or Designee will be responsible.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (# 1) who had documented medication refusals. Findings include, but are not limited to: Resident 1's clinical record and MARs were reviewed during the survey and revealed the resident had multiple medication refusals between 01/01/26 and 01/12/26. The medications refused included: * Lidocaine 4% Patch (for pain); * Oxybutynin 5mg (for overactive bladder); * Senna 8.6 mg (for constipation); * Acetaminophen 500 mg (for pain management); and * Triamcinolone 0.1% ointment (for rash). There was no documented evidence the facility notified the physician when the resident refused consent to their orders. On 01/14/26 at 4:30 pm the failure to notify physicians of the documented medication and treatments refusals was reviewed with Staff 1 (Administrator), Staff 2 (Wellness Director, LPN), Staff 3 (RN), and Staff 4 (RCC). They acknowledged the findings. No further documentation was provided.

Evergreen Memory Care will ensure resident medication and/or treatment refusals are communicated to Physician or Practitioner as requested by prescriber. Daily audits will be completed by HSD, or Designee to be in compliance. Audits will be reviewed in monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. All staff in-service to be held on Febuary 10, 2026. Training topics to include medication and treatment refusals. ED, HSD, charge nurse and/or Designee will be responsible

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

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

Based on interview and record review it was determined the facility failed to ensure an accurate MAR was kept for 1 of 4 sampled residents (#2) whose MAR was reviewed. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2025 with diagnoses including dementia. Review of the resident's MAR, dated 01/01/26 through 01/12/26, identified the following inaccuracies: * The MAR lacked parameters and PRN instructions for Tylenol, hydrocodone, and morphine (all for pain), and for Miralax and senna (both for constipation); * Orders for two discontinued medications (Hydrocodone every 6 hours, discontinued on 01/10/26, and Hydrocodone twice per day, discontinued on 01/10/26) were still on the MAR; * An order dated 01/11/26 for Hydrocodone, give every six hours as needed, was not on the MAR; and * The nursing PRN pain scale parameter for Tylenol to give when pain was 1-4 was given and noted as ineffective when the pain level was documented as 5 and 10. The need to ensure an accurate MAR was kept was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director, LPN), Staff 3 (RN), and Staff 4 (RCC) on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will ensure Medication Administration Records (MARs) will be accurate. Daily audits will be completed by HSD, or Designee to be in compliance. Audits will be reviewed in monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. All staff in-service to be held on Febuary 10, 2026. Training topics to include accuracy of MARs. ED, HSD, charge nurse and/or Designee will be responsible.

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.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

Based on interview and record review it was determined the facility failed to ensure a PRN psychotropic medication was only used for the specific reason for which it was prescribed, after documented non-pharmacological interventions had been tried with ineffective results, and failed to ensure the MAR included instructions for when to contact a health professional for 1 of 1 sampled resident (#2) who was administered a PRN psychotropic medication. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2025 with diagnoses including dementia. Review of the resident's progress notes, 01/01/26 through 01/12/26 MAR, and current signed orders identified the following: The resident was prescribed PRN Haloperidol (for agitation) and was administered the PRN on 01/09/26. The medication was noted to be ineffective. There was no documented evidence in the resident’s clinical record that identified the resident was experiencing the specific reason for use (agitation), there were no documented interventions attempted with ineffective results before the PRN was administered, and there were no instructions for when to contact a health professional, including when the PRN was ineffective. The need to ensure a PRN psychotropic medication was only used for the specific reason for which it was prescribed, after documented non-pharmacological interventions had been tried with ineffective results, and to ensure the MAR included instructions for when to contact a health professional was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director, LPN), Staff 3 (RN), and Staff 4 (RCC) on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will ensure non-pharmacological interventions are documented prior to administration of Psychotropic medications. Daily audits of administered PRNs will be completed by HSD, or Designee to be in compliance. Audits will be reviewed in monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. All staff in-service to be held on Febuary 10, 2026. Training topics to include non-pharmacological interventions prior to administration of PRN Psychotropic medications. ED, HSD, charge nurse and/or Designee will be responsible.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

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 sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: During the entrance conference on 01/12/26 with Staff 2 (Wellness Director/LPN) and Staff 4 (RCC), the following was identified: * The facility was a one story MCC with four neighborhoods that were connected to each other through corridors and a central resident common area. The neighborhoods were defined as Cascades: rooms 101-114; Rockies: rooms 115-128; Andes: rooms 129-142; and Sierras: rooms 143-156. * The facility had a current census of 48 residents. * Five residents required a two-person assist to transfer and/or for ADL care. Two of the five residents resided in Cascades neighborhood, two resided in Sierras neighborhood, and one resided in Rockies neighborhood. Based on the ABST facility questionnaire, the following was reported by Staff 1 (Administrator) and Staff 2 on 01/14/26 at 2:38 pm: * Seven residents required meal assistance; * 14 residents required support for behavioral symptoms; and * All 48 residents required supports for cognitive impairments. The facility's posted staffing plan, staffing schedule from 01/01/26 to 01/12/26, and total direct care time based on resident acuity and the facility acuity-based staffing tool (ABST) were reviewed. The posted staffing plan: * Day Shift: 6:00 am - 2:00 pm - 4 CGs and 2 MTs; * Swing Shift: 2:00 pm - 10:00 pm - 4 CGs and 2 MTs; and * Night Shift: 10:00 pm - 6:00 am - 2 CGs and 1 MT. The ABST indicated the day shift should have a minimum of 6.5 direct care staff. The staffing schedule showed 33% of the scheduled shifts from 01/01/26 to 01/12/26 were understaffed per the facility’s ABST. During an interview on 01/13/26 at 9:06 am, Staff 12 (Health Services Staff/CG) stated there was not enough staff to meet the needs of the residents. Staff 11 stated when Resident 1 refused a shower there was no other staff to attempt re-approach due to behaviors per Resident 1’s service plan and, therefore, at times, the showers were not completed. In an interview with Staff 4 (Resident Care Coordinator) on 01/13/26 at 10:00 am, she stated the facility was understaffed. Staff 4 revealed there was one staff member per neighborhood. If a staff member was providing shower assistance the neighborhood was left unattended. Cleaning and showers at times were not getting done based on limited staffing. Staff 4 stated overnight shift was particularly difficult as the community had four neighborhoods with three staff members covering. Residents who required two person transfers meant some neighborhoods were left unattended during those tasks. During an interview on 01/13/26 at 12:30 pm, Staff 14 (Health Services Staff/CG) stated she felt the facility was understaffed. Staff 14 stated residents that required a two person transfer often had to wait for transfer until another staff member was available. During an interview on 01/13/26 at 3:00 pm, Witness 1 (Family Member) stated there was not enough staff to meet the needs of the residents. Witness 1 stated the facility previously had more staff scheduled, two Health Services Staff/CG’s and one Health Services Staff/MT for every shift, but that had changed due to new ownership. Witness 1 stated residents were often left alone if the Health Services Staff/CG had to attend to a specific resident’s care needs as there was no one else there. In an interview with Staff 15 (Health Services Staff/CG) on 01/14/26 at 8:20 am, he stated that he felt like the section he worked in (Andes) could use an extra person because it was a “heavier section.” He didn’t always have an extra person around for two- person transfers and he had to wait sometimes, causing a resident to have to wait until after breakfast to get out of bed. Subsequently, the resident must sometimes eat his/her meal in bed instead of going to the dining room. The lack of staff also made it difficult to supervise everyone and complete required housekeeping and ADL tasks. The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents was discussed with Staff 1, Staff 2, and Staff 4 on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will accurately capture care time and care elements team members provide to residents and will staff accordingly with ABST. Residents' corresponding ABST evaluations will be updated and updated as needed. Weekly audit of the Health Services schedule will be completed by ED and HSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to ensure compliance and evaluate internal system to keep in compliance. ED and HSD will be responsible

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 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

Based on observation, interview, and record review it was determined the facility failed to accurately capture care time and care elements that staff were providing as outlined in the individual service plan for 1 of 4 sampled residents (#2) whose ABST was reviewed. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2025 with diagnoses including dementia. Observations and interviews with Health Services Staff (#’s 7, 10, and 12) identified the resident was being assisted with toileting, mobility, and transfers during the survey. The resident’s evaluation and service plan, dated 11/06/25, and subsequent service plan changes instructed staff to assist with toileting and with hearing aids and noted s/he was a moderate assist level with decision making. The ABST evaluation, last updated on 11/24/25, identified the following care time and care elements had zero minutes assigned: * Mobility; * Transfers; * Toileting; * Interests, hobbies, social, leisure activities; * Cognition including decision making ability; * Communication including assistive devices for hearing; and * Non-pharmaceutical interventions for pain. The need to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director, LPN), Staff 3 (RN), and Staff 4 (RCC) on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will accurately capture care time and care elements team members provide to residents. Residents' corresponding ABST evaluations will be updated and updated as needed. Weekly audits will be completed by ED and HSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to ensure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. ED and HSD will be responsible.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and in good repair. Findings include, but are not limited to: The facility consisted of a common area in the center, with four neighborhoods off the common area, including: Cascades, Rockies, Sierras, and Andes. The interior of the environment was toured on 01/12/26 at 11:00 am. The following was noted: Cascades Neighborhood: * Kitchenette had areas with gouged dry wall and missing paint; * Handrail in the kitchen alcove area had multiple areas of chipped/missing paint, creating a non-cleanable surface; and * Chipped paint and gouges on resident unit doors, including 109 and 112. Rockies Neighborhood: * Chipped paint and gouges on resident unit doors, including 124 and 128; * Alcove area opposite kitchen had sections of missing paint; * Dining room chair with vinyl torn from armrests; * Kitchenette had areas with gouged dry wall and missing paint; and * Sticky tape residue was noted in two square patterns in front of the laundry area. Sierras Neighborhood: * Chipped paint and gouges on resident unit doors, including 147, 150, and 153; and * Kitchenette had areas with gouged dry wall and missing paint. Andes Neighborhood: * Kitchenette had areas with gouged dry wall and missing paint; * Alcove area opposite kitchen had areas of chipped paint; * An area of the dining room floor had pulled up or was missing vinyl; * Chipped paint and gouges on resident unit doors, including 132, 137, and 139; and * Apartment 138 bathroom had a hole in the drywall near the sink, two walls had areas of missing paint, and there was brown/black matter around the base of the toilet. On 01/13/26, during a walk-through with Staff 16 (Maintenance) and Staff 1 (Administrator), the areas in the neighborhoods that required cleaning and/or repair were reviewed. Staff acknowledged the findings.

Evergreen Memory Care will ensure community's environment is kept clean, in good repair, and free from unpleasant odors. Weekly audits will be completed by Maintenance Director to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurment meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. All staff meeting to be held on February 10, 2026. Training topics to include community's environment, and Maintenance log to report any concerns. All enviromental items identified during survey not in compliance will be corrected. ED and Maintenance Director will be responsible

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans.

Based on observation and interview, it was determined the facility failed to ensure water temperatures in resident common use bathrooms and adjacent resident apartments were maintained between 110 and 120 degrees F. Findings include, but are not limited to: During an environmental walk-through and temperature check of resident common use bathrooms and adjacent resident room bathrooms, the following temperatures were noted: Rockies Neighborhood: * 01/12/26 at 11:00 am, 51.9 degrees F in common use bathroom; * 01/13/26 at 8:48 am, 49.6 degrees F in common use bathroom; * 01/14/26 at 10:30 am, 51.8 degrees F in Resident 127’s apartment; and * 01/14/26 at 10:30 am, 49.2 degrees F in Resident 128’s apartment. Sierras Neighborhood: * 01/12/26 at 11:00 am, 53.2 degrees F in common use bathroom; * 01/13/26 at 9:30 am, 50.9 degrees F in common use bathroom; * 01/14/16 at 10:35 am, 51.8 degrees F in Resident 156’s apartment; and * 01/14/16 at 10:35 am, 52.3 degrees F in Resident 155’s apartment. The water temperatures in the common use bathroom and adjacent resident apartments were found to be cold to the touch. The temperatures were reviewed and discussed with Staff 6 (Maintenance Assistant) on 01/12/26 at 2:45 pm. Staff 6 verified the cold temperatures. During an interview on 01/14/26 at 10:35 am, Staff 16 (Maintenance) stated he would contact a plumber to address the low water temperatures.

Evergreen Memory Care will ensure water temperatures maintain a rage of 110 - 120 degrees F. Weekly audits will be completed to assure compliance. Audits will be reviewed in Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. ED and Maintenance Director will be responsible

OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans.

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

Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own bathroom for 1 of 4 sampled residents (#3) and multiple un-sampled residents who shared bathrooms. Findings include, but are not limited to: The resident units consisted of single and double occupancy (shared) units. Resident 3 resided in a double occupancy room that shared a bathroom. Multiple un-sampled residents were noted to share a bathroom. The shared bathrooms were without a locking mechanism on the inside of the bathroom door to ensure privacy when in use. During an interview on 01/14/26 at 9:37 am, Staff 16 (Maintenance) and Staff 1 (Administrator) confirmed that multiple shared bathroom doors lacked locking mechanisms to ensure privacy while the residents were in the bathroom.

Evergreen Memory Care will ensure residents' right to privacy in shared units. Lockable lever door knobs have been purchased and will be installed to be in compliance. All staff meeting to be held on February 10, 2026. Training topics to include restroom door locks for privacy. ED and Maintenance Director will be responsible

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

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

Based on interview and record review, the facility failed to ensure move-in evaluations addressed all required elements, including gender identity, for 1 of 1 sampled resident (# 4) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to C252.

Please refer to POC for C252. Facility

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

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

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C360, C362, C513, and C545.

Refer to POC for C360, C362, C513, C545.

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

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

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, C303, and C310.

Refer to POC for C260, C270, C303, C310.

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

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

Based on interview and record review, it was determined the facility failed to evaluate the residents for activities and develop an individualized activity plan based on their activity evaluation for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose activity plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4’s activity evaluations were requested on 01/13/26 and service plans were reviewed during survey. No activity evaluations were identified. The facility had not evaluated the residents’: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for participation; and * Activities that could be used as behavioral interventions. There was no individualized activity plan developed for each resident based on his/her activity evaluation which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities. The need to develop individualized activity plans which were based on an evaluation of the resident's interests, abilities, and needs was discussed with Staff 5 (Life Enrichment Director) on 01/13/26 at 2:52 pm. Staff 5 acknowledged the findings.

Evergreen Memory Care will ensure activity evaluations address all required elements. Moving forward, all admissions will have a completed Resident Evaluation to address all required elements. All sampled resident's evaluations will be updated to address all required elements. Weekly audits will be completed by ED and HSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. ED and RSD will be responsible.

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

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility main kitchen and the four unit kitchenettes occurred on 08/07/25 from 11:00am thru 1:30 pm and identified the following. a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * All unit kitchenette cabinets under the sink with black debris buildup * Kitchenette corner cabinets in multiple units b. The following areas needed repair: * All unit kitchenette cabinets under the sink with significant water damage to cabinets, piping with black debris buildup and/or evidence of water leakage. * Microwave in Rockies unit observed with burn damage and multiple unsmooth/non cleanable areas and was in need of replacement. * Pipe entering/exiting main kitchen ceiling with gaps around piping c. Main hand wash sink in main kitchen area did not have a splash guard to prevent potential contamination. Clean dishes and a toaster were observed stored right next to sink. Another sink in the back of the kitchen had rags/clothes/debris stored in the sink bowl/basin area rendering it unusable. Staff 2 (Dining Services Director) acknowledged the sink in the back of the kitchen was not used very often by staff. At 1:00 pm, surveyor reviewed identified areas with Staff 1 (Administrator). Staff 1 acknowledged areas needing correction.

Under the kitchette sinks that was found to be deficent will be corrected by the maintiance director cleaning the pipes and replacing the sections of pipe that are leaking. Rubber mats will be placed on the floor under the sinks. Checking this area for clealiness will be added to the RCC daily check sheet. The Microwave in the rockies has been replaced All microwaves are added to the NOC shift cleaning checklist and will be monitored by the RCC The Gap around the pipe entering the kitchen celing will be filled in by the Maintiance director Using spray foam insulator. A splash guard will be placed at the hand washing sink to help avoid potential contamination. The DSD will monitor for effectiveness. The sink in the back of the kitchen will not be used to store anything any longer. The DSD will monitor daily for compliance.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

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

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

Refer to C240.

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

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main facility kitchen and the memory care unit kitchenettes on 08/05/24 from 10:30 am through 2:00 pm revealed the following deficient practices: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Fan above reach in fridge cages and blades; * Reach in refrigerator by beverage area in kitchen; * Industrial can opener blade; * Stainless steel shelving in baking/prep area; * Ceiling of microwave; * Reach in refrigerator in Rockies unit; * Toasters in units; * Lazy Susan cabinets in units; * Kitchenette floors in units; and * Table bases in Cascades unit. b. The following areas needed repair: * Caulking in ware washing area with black matter debris buildup; * Cabinets under microwave in units with shelving with exposed pressed/porous wood making non-cleanable surfaces; and * Reach in refrigerator in kitchen by beverage station reading 50 degrees during survey. c. Kitchen staff member observed to handle dirty dishes and reach into garbage disposal and handle lemons with the same gloves that they then handled clean dishes. No hand hygiene step was observed when going from a dirty task to a clean task as required. d. Thermometer in a reach in refrigerator holding resident beverages, multiple condiments, whipped topping and a pasta salad for evening meal was observed to be at 50 degrees. The thermometer was located in the door at the warmest portion of the fridge. Surveyor moved thermometer to the back/coldest part of the fridge and rechecked the temperature which dropped to 46 degrees but still above the required 41 degrees for cold storage. Review of refrigerator temperature logs revealed multiple days in May and July that the same fridge had been noted to be above 41 degrees and at times at 50 degrees. No evidence was found that the facility identified the incorrect and unsafe storage temperature of the fridge and made appropriate corrective actions to ensure food/beverages were being stored at the appropriate temperatures. e. Multiple small black ants were observed crawling on the floor around the small reach in refrigerator in Cascades unit. The ants were observed to crawl in/out of the broken seals in the floor/wall cove base. In an interview on 08/05/24 at 1:45 pm, Staff 1 (Executive director) and Staff 2 (Dining Services Manager) were informed of concerns found. Both staff 1 and 2 acknowledged areas in need of correction. Staff 2 was asked about the refrigerator temperatures and indicated whenever they checked the temperature it was at 41 degrees or below as required but indicated it was first thing in the morning and that the other cook checked the temperature in the afternoon. Staff 1 was unaware that the refrigerator was not effectively holding temperatures at 41 degrees or below and acknowledged there was no evidence that the appropriate interventions were put in place when temperatures were documented above the 41 degrees. Staff 1 indicated they would have maintenance look at the fridge and see if it could be adjusted to be cooler and that anything potentially hazardous would be discarded. If the current fridge could not maintain temperature, it would be repaired or replaced.

A. All areas in the main kitchen noted to need cleaning have been deep cleaned and will remain on a deep cleaning schedule monitored by the DSD. All areas of the kitchenetts noted to need cleaning have been deep cleaned and will remain on a weekly deep cleaning schedule monitored by the resident care coordinator. B. The caluking around the wall at the back of the dish area will be replaced and added to the deepcleaning schedule monitored by the DSD. The Cabninets under the nicrowaves in the units will have the edging replaced as to repair the non cleanable surfaces. The refrigerator noted to be at 50 degrees at survey has been turned down and has been monitored daily by DSD and is reading below 41 degrees. we will continue to monitor daily and replace or repair if needed. The particle board making up the bottom of the cuppards under the sinks have been replaced closing up the open cut out areas. The pipes have all been inspected and cleaned. The items under the sinks have been removed . C. A staff training on hand hygiene for clean and dirty tasks will be heald by the DSD. DSD will monitor kitchen staff  daily to ensure that procedures are being followed. D. A staff training on logging refrigerator temps and when to report them to the DSD will be held. The DSD will monitor the temps daily to ensure that they are within range. E. The kitchette floor has been cleaned and the ants have been removed. The small crack in the caulking on the floor trim has been repaired.

Based on observations, interviews and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240.

Refer to POC for C240

The findings of the kitchen inspection, conducted 08/05/24, 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. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

The findings of the revisit to the kitchen inspection of 08/05/24, conducted 10/04/24, 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, it was determined the facility failed to ensure the move-in evaluation addressed all required elements for 1 of 1 sampled resident (#2) who was recently admitted to the facility. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2023. The move-in evaluation, completed on 06/13/23, failed to address the following required elements: * Spiritual, cultural preferences and traditions; * Mental Health issues including: presence of depression, thought disorders or behavioral or mood problems; history of treatment; and effective non-drug interventions; * Pain: non-pharmaceutical interventions; * Complex medication regimen; * History of dehydration; and * Elopement risk or history. The need to ensure all required elements were addressed in the move-in evaluation was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN) on 07/11/23. They acknowledged the findings.

1.) Each resident identified as being out of compliance has been brought in to compliance. 2.) Our move in assessment has been check over and meets all requirments of the OAR if filled in completely. At each move in assessment the nurse will ensure that all of the questions are fully answered by the resident or resident family. If resident is unwilling to answer any questions at assessment the nurse will follow up with the resident and family again prior to move in to ensure all resident specific information is entered. 3.) Move in assessment will be evaluated by clinical team prior to move in. 4.) Clinical team consisting of Admin, Wellness director and RCC will monitor

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided a written description of who shall provide the services and what, when, how, and how often the services shall be provided for 1 of 5 sampled residents (#5) whose service plans were reviewed. Findings include, but are not limited to: Resident 5 was admitted to facility in 06/2022 with diagnoses including dementia and repeated falls. The current service plan dated 05/14/23 and Interim Service Plans (ISP's) from 04/11/23 to 07/01/23 were reviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas: * Level of assistance required for transfers and toileting; * Modified diet requirements; and * Use of side rails, including safety checks. The need to ensure service plans were completed quarterly, were reflective of residents' current needs and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Administrator) and Staff 2 (Wellness Coordinator/LPN) on 07/11/23 at 2:05 pm. They acknowledged the findings.

1. All residents' care plans found out of compliance have been reviewed, and corrected by using the care planning team consists of wellness director, caregiver, RCC family, and resident as able. 2.) Care planning team will meet and discuss the next weeks care plans that will be due. Team will discuss the residents current care needs and the wellness director will take all TSPs and information gathered at the care planning meeting and make adjustments to  ensure that each area of the care plan will reflects the residents current care needs. 3.) Care plans will be evaluated at move in, 30 days and then quarterly. 4.) The Wellness director will ensure that all corrections are completed

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose service plans were reviewed.  Findings include, but are not limited to: Resident 1, 2, 3, 4, and 5's most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans. On 07/12/23 the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/ LPN), and Staff 13 (Regional RN). They acknowledged the findings.

1.)  All residents' found out of compliance have been reviewed and corrected, using the care plan team of Wellness director, Admin, RCC caregiver, family, and resident as able.  Signatures of the care planning team are documented. 2.)  Care plan meetings completed weekly for the next weeks care plans that are due. Care plan team will consist of the RN, Admin, direct care staff, family, and the resident, as able. Signatures of care plan team will be collected on the signature page. 3. Wellness Director or delegate will review evaluation schedule weekly, schedule care plan meetings, and enter information into the system. The system will be evaluated weekly to ensure within compliance. 4. Wellness Director/Delegate/Admin

2. Resident 5 was admitted to the facility in 06/2022 with diagnoses including dementia and repeated falls. Observations of the resident, interviews with staff, and review of the resident's service plan dated 05/14/23, and progress notes dated 04/01/23 through 07/07/23 were completed. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident and communication of the determined actions or interventions to staff on all shifts: * 04/11/23 - Fall out of bed with head injury; * 06/17/23 - Fall out of wheelchair; and * 06/27/23 - Dietary change to pureed diet. The need to ensure short-term changes of condition had actions or interventions determined documented in the resident record and were communicated to staff on all shifts was discussed with Staff 1 (Administrator) and Staff 2 (Wellness Coordinator/LPN) on 07/11/23. They acknowledged the findings, and no additional documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to determine, document, and communicate resident-specific actions or interventions needed for 2 of 5 sampled residents (#s 2 and 5) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2023 with diagnoses including Alzheimer's disease. During the acuity interview on 07/10/23, Resident 2 was identified as having recently experienced a "rapid decline." Staff 3 (Resident Care Coordinator) and Staff 11 (Med Tech MC) both reported s/he was able to walk independently, feed him/herself, and interact with staff when s/he was admitted to the facility, and in a short period of time s/he became bedbound, non-responsive, and unable to eat. The resident's clinical record was reviewed, staff were interviewed, and observations were made. Interviews with Staff 8 (Care Partner MC), Staff 17 (Care Partner MC), and Staff 11 (Med Tech MC) on 07/10/23, 07/11/23, and 07/12/23 confirmed the information about Resident 2 presented in the acuity interview. Between 07/10/23 and 07/12/23 the resident was observed to be in bed during the entire survey. Staff were observed attempting to feed him/her on 07/11/23, but s/he was not responsive and did not eat anything. There was no documented evidence in the resident's clinical record of his/her recent decline or instructions to staff about changes in his/her ADL care needs. The need for actions or interventions to be determined, documented, and communicated with all staff was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN) on 07/11/23 and 07/12/23. They acknowledged the findings.

1.)  Residents identified as being out of compliance having due to having change of condition have been assessed by the RN. Needed interventions put in place. Changes of conditions communicated to the resident's physician and staff. 2.)  All Staff have been trained on how to identify changes of condition (COC) and reporting expectations. Staff were aslo trained on documentation expectations. Nursing will assess the reported changes, iniciate a new (COC) assesment and careplan that reflects new care needs. Staff will review and sign the new care plan acknoledging the changes. Nursing will monitor change in conditions and review interventions for effectiveness. 3.) Clinical team will monitor daily the resident chart notes, incident reports and weights to identify possible changes in condition. The new implemented Significant Change form are reviewed daily with follow up evaluation. Weekly written chart note of the progress of implemented interventions. 4. Wellness Director/Delegtate/Admin

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN in a timely manner for 2 of 3 sampled residents (#s 1 and 2) who experienced significant changes. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2023, already on hospice, with diagnoses including Alzheimer's disease. During the acuity interview on 07/10/23, Resident 2 was identified as having recently experienced a rapid decline. A review of the resident's clinical record and interviews with staff identified the following: * When the resident was admitted to the facility in 06/2023, s/he was ambulating and eating independently and spent time each day walking around the unit. * The resident experienced a fall on 06/27/23. * Staff reported after the fall the resident stopped ambulating, was unable to feed him/herself, and became bedbound and "mostly" non-responsive. * Hospice indicated to staff the resident was in a "pre-transition" phase. There was no documented evidence the RN had completed a significant change of condition assessment which documented findings, resident status, and interventions made as a result of the assessment, and the service plan was not updated. The RN was unavailable for interview during the survey. The need to ensure a significant change of condition assessment was completed by an RN within 48 hours was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN). They acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2022 with diagnoses including Alzheimer's disease. A review of the resident's record identified the following weights: * 04/01/23:  181.8 lbs.; * 06/01/23:  176 lbs.; and * 07/01/23:  165 lbs. Between 04/01/23 and 07/01/23 the resident lost 16.8 lbs., or 9.24% of his/her total body weight, in three months. This was a severe weight loss and constituted a significant change of condition. Between 06/01/23 and 07/01/23 the resident lost 11 lbs., or 6.25% of his/her body weight, in one month. This was a severe weight loss and constituted a significant change of condition. A review of the resident's progress notes revealed a significant change of condition assessment was completed by the RN on 07/07/23, over a week after the weight loss was triggered. The facility's RN was unavailable for interview during survey. The need to ensure significant change assessments were completed by the RN in a timely manner was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN) on 07/12/23. They acknowledged the findings.

1.)  Residents identified as being out of compliance having due to having change of condition have been assessed by the RN. Needed interventions added . 2.) Clinical team will meet daily and review all notes from the prior day as well as incidnet reports and new weights as to identify changes in condition. RN will iniciate an COC assessment for any new changes of condition found. If RN is not present LPN will iniciate COC by adding a chart note and notifying the RN. Staff training on how to identify COC and requirements for reporting COC's to the licsensed nurses have been held. 3. Chart notes and incident reports will be reviewed daily at our clinical meeting. 4. Wellness Director/Delegate/Admin

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure staff were informed of new interventions, adjust the service plan if necessary, and ensure reporting protocols were in place for 1 of 3 sampled residents (# 2) who received outside services. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2023 with a diagnoses of Alzheimer's Disease with behavioral disturbances. Resident 2's outside provider notes, dated 06/14/23 through 07/10/23, were reviewed, and the following changes in pain and new skin concerns were identified: * 06/22/23 Certified Nurses Aide (CNA): "lethargy, lower ability to ambulate, new behavior/grabbing"; * 06/28/23 CNA: "agitated during cares. Sm red area on bottom, two small red areas on L forearm, R knee-small"; * 06/29/23 CNA: "Ribcage looks swollen - R side more swollen than Left. [Resident 2] stated nothing was painful. Eyes-skin near inner R eye red - and L outer red"; * 06/30/23 CNA: "Declined taking off shirt and asked this CNA to stop when this CNA was washing stomach-chest. Patient was guarding [his/her] chest. Ribcage on both sides - swollen and painful. Discharge out of eyes - painful when gently wiping eyes - asked to "Not do that"; * 6/30/23 RN: "orders for eye cream to follow and schedule tylenol"; * 07/03/23 CNA: "declined a new shirt guarding chest and pulled shirt down. Feet cold and toes look purple. Lips look blue. Eyes - skin - red and painful when wiping. Painful when R arm touched. Seeing things and talking about tweezers that [s/he] needs to take to the cows. Lower ribcage swollen"; * 07/05/23 CNA: "new-Red area on R elbow and slightly swollen. Ribcage swollen. Toes appear slightly purple and lips appear blue. Painful when dressing and rolling"; * 07/06/23 CNA: "redness on R elbow - R elbow painful to touch. Skin around eyes - red"; and * 07/07/23 RN: "painful to right elbow when touched, some swelling noted. Fidgeting with eyes closed." There was no documented evidence staff were informed of new interventions and the service plan was adjusted to ensure continuity of care. The need to coordinate care with outside providers, inform staff of new interventions, adjust the service plan when needed, and have reporting protocols in place was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN) on 07/12/23. They acknowledged the findings.

1. All residents' found out of compliance have been reviewed and corrected. Each residents Outside provider notes have been rechecked to ensure that all information was followed up on. 2.) Our Three check system has been re evaluated with the RCC doing first checks, LPN doing second checks and RN doing the third and final checks to ensure that all outside provider care is coordinated appropriately. 3.) Wellness director and Admin will monitor system weekly to ensure compliance 4.) Wellness director and Admin

Based on interview and record review, it was determined the facility failed to ensure medications administered by the facility were set-up and documented by the same person who administered the medications for 1 of 5 sampled residents (#2). Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2023 with diagnoses including Alzheimer's disease with behavioral disturbances. The resident's clinical record was reviewed and the following was identified: A progress note dated 06/15/23 stated: "[The resident] did not like me, and would not take the medicine from me. I got care partner to give it to [him/her]." In an interview on 07/11/23, Staff 1 (Administrator) indicated she was "surprised" the med tech would have a care partner administer medication to a resident. She stated she would investigate and speak with the med tech. The need for all medications to be administered by trained med techs and for medications to be administered and documented by the same person was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/LPN), and Staff 13 (Regional RN). They acknowledged the findings.

1.) Med tech was counseled and med tech training was held on appropriate ways to handle medication refusals and the need for medications to be passed and documented by the same person. 2.) RCC will do quarterly audits of med passes with each med tech to ensure that all med techs are following policies and procedures. 3.) Quarterly audits will be held. 4.) RCC, Wellness director and Admin will follow

Based on interview and record review, it was determined the facility failed to ensure the ABST (Acuity Based Staffing Tool) was updated at least quarterly and following changes of condition, to determine appropriate staffing levels to address activities of daily living and other tasks related to care for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5). Findings include, but are not limited to: Observations, interviews, and review of clinical records, including service plans for Residents 1, 2, 3, 4, and 5, revealed the facility's ABST tool was not updated quarterly and when there was a significant change of condition to reflect the residents' care needs, in order to ensure the ABST was accurately determining the needed staffing levels. On 07/12/23 the need to ensure the ABST tool was updated to determine appropriate staffing levels to address activities of daily living and other tasks related to care was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/ LPN), and Staff 13 (Regional RN). They acknowledged the findings.

1.) All care plans have been compared against the ABST and necessary adjustments have been made to ensure all resident cares are correct. 2. RCC will update the ABST when the Care plans are updated. Wellness director will give RCC a daily list of care plan updates at the daily clinical meeting. 3.) ABST will be updated for new move ins, 30 day eval, each quarterly eval and COC's. Residents will be removed once discharged. Wellness director and Admin will do weekly checks for accuracy. 4.) RCC, Wellness director, Admin

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 361.

Plan of correction : Refer to C252, C260, C262, C270, C280, C290, C301, C361 and Z163

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C260, C 262, C270, C 280, C 290, and C 301.

Plan of correction : Refer to C252, C260, C262, C270, C280, C290, C301, C361 and Z163

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, 4, and 5's current service plans were reviewed during survey. Each service plan lacked information and staff instructions related to the individualized nutrition and hydration status and preferences and needs of the resident. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator) and Staff 2 (Wellness Coordinator/LPN) on 07/11/23. They acknowledged the findings.

1.) Each care plan found to be missing individualized nutrition and hydration plan has been updated. 2.) At each move in assessment the nurse will ensure that questions are fully answered by the resident or resident family. If resident is unwilling to answer any questions at assesment the nurse will follow up with the resident and family again prior to move in to ensure all resident specific information is entered. Nurse will check in with caregivers periodically to gather information about the residents likes and dislikes to add to careplan as well. 3.) Move in assesment will be evaluated by clinical team prior to move in to ensure individualized information is present. 4.) Clinical team consisting of Admin, Wellness director and RCC will monitor

The findings of the re-licensure survey, conducted 07/10/23 through 07/12/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the re-licensure survey of 07/12/23, conducted 11/13/23 through 11/14/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

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, food storage areas, food preparation, and food service on 11/15/22 revealed splatters, spills, drips, and debris noted on:   - Can opener blade and casing; - Stand mixer; - Food Processor; - Interior and exterior of the microwave; - Walls in food preparation area; - Interior of reach in freezer; - Food packages and containers in dry food storage area;, - Dishes and cookware stored on open shelving and racks; - Open stainless steel shelving and metal rack shelving; - Top of black reach in refrigerator and juice machine, - Ceiling vent above black reach in refrigerator; - Plastic knife case hanging on the wall; - Bakery racks; - Front grate of the ice machine; - Underneath shelving and equipment; - Floor of the walk in refrigerator; - Dishwashing area including flooring, walls, and equipment; and - Radio. * The stand mixer blade was noted to have the finished chipped off. * Cutting boards were deeply scored and flaking off pieces. * Open packages and dented cans were noted in the dry food storage area. * Dish washing racks were stored on the floor. Visible debris was noted on the clean side of the dish machine. * The rinse cycle thermometer on the dish machine was not operating. * Staff were using a mixture of bleach and dish soap for sanitizing. There was no evidence of testing the solution to ensure between 50 and 110 parts per million. When tested, it was above 200 parts per million. * Staff were observed to not change gloves between tasks while handling ready to eat foods. Observations of the kitchenettes on 11/14/22 revealed: * Splatters, spills, drips, and debris noted on: - Interior and exterior of cupboards and drawers and walls; - Outer surfaces of garbage cans and hampers; - Interiors of mini-refrigerators; - Interior and exterior of microwaves;and - Flooring and cove base. * Undated and unlabeled storage bags of cookies and rolls were noted in a drawer. * Food wrapped in aluminum was observed left in a microwave. * The mini-refrigerator/freezers were noted to have frost build up in the freezers and damage to the shelving in the refrigerators. Staff 2 (Dietary Manger) and the Surveyor toured the kitchen. Staff 2 acknowledged the above findings. The areas in need of cleaning and repair were reviewed with Staff 1 (Administrator). She acknowledged the findings.

-Areas of the kitchenetts were noted to have spills of has been cleaned and an updated cleaning schedule has been published to ensure all areas remain in compliance. -All undated foods have been removed and staff have been trainied on dating any foods opened and proper storage policies. Resident care coodinator and Administrator will ensure compliance. -The mini fridges have been defrosted and cleaned. The damaged fridges have been replaced. -All areas noted that required cleaning have been cleand and an updated cleaning schedule has been published. Dining srevices director inspects daily cleaning and submits weekly quality assurance checklist to the Administrator. -Administrator will do weekly and as needed spot checks to ensure compliance with the cleaning requirements.

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. This is a repeat citation.  Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 1/19/23 revealed splatters, spills, drips, dust and debris noted on:   - Dishwashing Equipment; and - Fire sprinkler heads. * White cutting board on steam table was found to be deeply scored and stained. * Dish washing rack was observed stored on the floor. * Hole in the wall exposing electrical and piping found on the back left wall by the baking rack. *The rinse cycle thermometer on the dish machine was not operating correctly. The rinse dial was reading 170 and did not move. The wash cycle thermometer did not quite get to 180. The dish machine temperature logs were reviewed and revealed multiple readings that were not at the required 180 F for sanitation. Staff 2 (Dietary Manager) stated the process when dish machine was not operating correctly was to utilize the 3 compartment sink method. Staff 2 validated s/he was not notified when temperatures were not reaching 180 and could not verify that a 3 compartment sink method was utilized under those circumstances. Staff 2 utilized an instant read digital thermometer to validate rinse temperature was at 181.3 F after 4 runs of machine. Kitchen staff stated that the temperature gages "never work right". Staff 2 did validate that the dish machine had been serviced multiple times that month and there were still problems with the temperature gauges. Staff 2 (Dietary Manger) and the Surveyor toured the kitchen. Staff 2 acknowledged the above findings. Observations of the kitchenettes on 1/19/23 revealed: * Splatters, spills, drips, and debris noted on: - Interior and exterior of cupboards and drawers; - Interior and exterior of microwave; and - Flooring and molding. * One of the mini-refrigerator/freezer had damage to the shelving making it a non cleanable surface. One of four microwaves were found to be damaged making it a non cleanable surface. * Two coffee containers were found with scoops stored inside and touching the coffee grounds. * Under the sinks of all kitchenettes had a large cut out area in the cabinet. The underneath of these cabinets were dirty and had exposed particle board. Pipes were dirty with potential leaks on the pipes. One sink had a strong odor and visible standing fluid in a basin under the pipe. All areas had items stored  under the sink that could be potentially contaminated by dripping grey water from the sink (toasters, coffee makers). *Multiple cabinet interiors had exposed particle board in various areas. The areas in need of cleaning and repair were reviewed with Staff 1 (Administrator). She acknowledged the findings.

The are of the diswasher noted to need cleaning has been deep cleaned and will be monitored by the dietary supervisor. The fire sprinkler heads are being replaced by Performance systerms intergrated as they were not able to be cleaned to our satisfaction. The cutting board on the steam table has been replaced. The whole in the wall behind the bread rack has been repaired. The rinse cycle on the dish machine has been repaired and is reaching 180 degrees. A procedure for when to contact the dietary supervisor has been posted.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240.

Refer to C 240

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

All areas of the kitchenetts noted to need cleaning have been deep cleaned and will remain on a weekly deep cleaning schedule monitored by the resident care coordinator. Staff have been notified that they are no loner allowed to have the scoops left in the coffe containers. The dietary supervisor will be ordering indvidually bagged servings of coffee going forward to elemanate the need for coffee scoops. The refrigerator noted to have damage has been replaced and the microvave noted to have damage has been replaced The particle board making up the bottom of the cuppards under the sinks have been replaced closing up the open cut out areas. The pipes have all been inspected and cleaned. The items under the sinks have been removed .

The findings of the kitchen inspection, conducted 11/15/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 11/15/22, conducted 1/19/23, 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 Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 11/15/22, conducted 4/26/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.