New Friends Memory And Residential Care of Florence

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, record review, 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. Facility also failed to ensure diet texture orders were followed for residents along with provide meals at standard times. Findings include, but are not limited to: Observation of the main facility kitchen and house 2 and 3 kitchen areas were reviewed on 08/15 from 1:30 pm through 3:00 pm and again on 8/18/25 from 10:30 am thru 1:15pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Inside and outside of reach in coolers and freezers * Outdoor storage space floors, walls, ceiling where refrigerators and freezers were stored * Door thresholds to food storage areas * Open shelving in dry storage * Black plastic shelving * Flooring of pantry * Interior of microwaves * Industrial can opener and housing * Open shelving: * Drawers and cabinets storing clean dishes and other equipment * Cabinets, drawers, shelving holding/storing food b. The following areas were in need of repair: * Small holes in walls in kitchens. * Reach in refrigerator in house one not holding temperature at 41 degrees are below * Multiple exteriors of refrigerators with dirt and/rust on exteriors or with no handles * Multiple reach in refrigerators with large condensation and notable water leakage/build up * Microwave in house 2 with dents/damage * Flooring in house 3 with integrity flaws, chips, gouges yielding non-smooth surface * Multiple cupboard/cabinets/shelving with exposed porous wood and/or non-smooth surfaces. * Multiple refrigerators had water and/or excessive condensation in the refrigerators with water leakage/build up on shelves, food or beverage containers. c. Multiple food items found uncovered in reach in fridges. Multiple items without dates opened/prepared. Multiple items found past the manufactures use by dates and or facility date marking for use within 7 days. In house 3 a bag of hot dogs was observed that did not have a date and were visibly discolored and looked spoiled. A pan of dessert was loosely covered with plastic wrap where multiple areas of exposed food were noted. Pan of dessert was noted to have liquid contaminants from other areas of the fridge inside the food product where the open sections were. Staff was asked to discard the hot dogs and the dessert due to contamination and safety concerns. d. Refrigerator in house 1 thermometer reading 48 degrees Fahrenheit on 08/15/25. Mayonnaise temperature was checked and found also at 48 degrees Fahrenheit. Multiple items were stored in the refrigerator and limited open space was observed potentially creating cold circulation concerns. Staff 2 (Cook) indicated some items in the fridge (near the back) were freezing. Staff 2 was instructed to check the temperature of all potentially hazardous foods and discard any found at greater than 41 degrees. Upon return to facility on 08/18/25 the identified fridge was within acceptable temperatures (41 degrees) and was at maximum cold setting (7). e. Care giving staff were observed to not properly remove/change gloves and or wash hands when necessary during meals service on 08/18/25. Staff were observed to leave the kitchen with gloves on touch residents and or resident care equipment and return to kitchen area without removing/changing gloves. Other staff were observed entering kitchen from care areas and did not wash hands before donning gloves as required. f. On 08/15/25 at 2:00pm already prepared food items were observed tin the oven. Staff 2 was interviewed and revealed the food items were for dinner at 4:30 pm that day. On 08/18/25 at 12:30 pm, Staff 1 (Administrator) was interviewed and confirmed that on multiple days there was no evening cook to prepare dinner meal and that the morning cook prepared evening meal and care staff served the meal. Staff 1 acknowledged the food was being hot held for greater than 2 hrs on those days with no evening cook. Staff 1 and Staff 3 (Facility Representative) acknowledged that practice could impact food quality and palatability having food continue cooking process for that extended amount of time. g. Pans of food were observed in house 3 not held on or in a heat source and no covers or lids during service to keep hot food hot or food protected from potential contamination. Pans of food were observed uncovered for more than 20 minutes. h. Staff were observed in house 3 putting food off the stove in plastic containers for “left overs”. Staff were asked about proper cooling methods and what the time/temperature steps were for proper cooling. Staff was not able to correctly demonstrate knowledge of cooling or reheating temperatures/processes. i. Facility had multiple residents on Mechanical soft diets. Staff were interviewed regarding items that are available to be provided to residents on mechanical soft diets. Varied answers were given. Staff did not have guidance to refer to in kitchen areas for appropriate foods for mechanical soft foods. Staff indicated they used to have a reference sheet to help them but didn’t know where it was. Multiple care staff indicated that they were the ones that would mechanicalize the food that the cook prepared for the residents and would “figure out” items as/if needed appropriate for the mechanical soft diet. Staff stated that if residents could not have a vegetable that was offered like lettuce for soft tacos, they would offer apple sauce or other fruit available. Staff 1 acknowledged that cook was not mechanicalizing food for mechanical soft diets. In house 3 a resident’s diet indicated Mechanical soft (ground) meat, resident was given cut up meat of various sizes/chunks none of which were ground. Vegetables on plate also included broccoli stems that were not fork mashable/soft. A whole roll with a hard/crusted bottom was also served. House 1 had a resident that was on mechanical soft on the list posted on the fridge however staff 4 (cook) was unaware any residents in that house were mechanical soft. Staff 1 was interviewed regarding the resident in house 1 on mechanical soft and indicated it was the resident’s preference to get a regular texture diet. Staff 1 acknowledged the diet order was still Mechanical soft and that the MD had not been informed of the resident’s preference to not follow mechanical soft diet. Staff 3 provided a typed sheet for Mechanical soft diets that included. “Tender meats (shredded or finely chopped), vegetables (soft, well cooked, pureed or smashed), breads (white bread, soft rolls or toast without crusts). None of the mechanical diets served for the lunch meal on 08/18/25 met criteria for mechanical soft. j. On 8/15/25 staff 2 informed surveyor of dinner meal times that was at 4 pm. When asked why dinner meal was at 4 pm, staff 2 indicated “it has just always been that way since I started.” Staff 2 acknowledged they felt 4 pm was early time for dinner. A care staff in house 3 indicated that dinner was at 4:30pm for their house. Surveyor inquired on why dinner was at 4:30 pm and they also did not know why and that “it has always been at 4:30 pm.” On 08/18/25 at 10:30 am staff 1 was asked about meal times and confirmed dinner is served at around 4:30 pm. They indicated they were not sure why it was 4:30 pm as it has been that way since they started. Staff 1 indicated most likely was because residents go to bed fairly early like 7 pm. Staff 1 indicated a snack was offered to residents if they wanted one but was not able to determine if it was a substantial snack indicating a protein source was given with the snack. Staff 1 acknowledged that dinner meal and breakfast meal was 16 hrs apart exceeding recommended maximum of 14 hrs. Staff 1 acknowledged that the facility could not determine or provide information that having dinner early with an extended time between meals was resident driven. k. Staff food storage items were observed stored in house 3 with resident food. Staff acknowledged that was their food and that there was a space for staff to store their food and should not be stored in with resident food items. l. On 08/15/25 at 2:38 a plate of food was observed sitting on the counter in house 3. Staff verified this was a plate of food for a resident from lunch. Staff indicated lunch was served at about 11:30 am. m. On 08/15/25 at approximately 3:00pm a non-staff member was observed in the house 2 kitchen. It was later determined this was a family member of a resident. This person was observed to be heating up some food brought in for the resident. The family member was using kitchen items/equipment and did not have a hair restraint and was not observed to wash hands. Family member did not check the temperature of the food warmed for resident to determine if reheated to correct safe temperatures. Facility staff was in the kitchen area with family member and surveyor. n. House 2 had a carpet/floor cleaning machine stored in where food is prepared, stored, served. Staff 1 acknowledged that piece of equipment should not be stored in the kitchen area. o. Reach in refrigerator located in the outdoor covered storage area was noted to have raw ground beef stored above pork(bacon) which is not according to proper storage of raw meat products. p. Registered dietitian reports for July documented concerns for dating of foods, food being out of date, cleanliness, concerns with hand hygiene and glove use, staff not following diets, improper meat storage and resident complaints on food quality. On 08/18/25 at approximately 12:45 pm, surveyor reviewed above areas with staff 1 (Administrator) and Staff 3 (Facility representative) who acknowledged the identified areas.

1. What actions will be taken to correct the rule violation for each example/resident? Observation of the main facility kitchen and house 2 and 3 kitchen areas were reviewed on 08/15 from 1:30 pm through 3:00 pm and again on 8/18/25 from 10:30 am thru 1:15pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Inside and outside of reach in coolers and freezers * Outdoor storage space floors, walls, ceiling where refrigerators and freezers are stored * Door thresholds to food storage areas * Open shelving in dry storage * Black plastic shelving * Flooring of pantry * Interior of microwaves * Industrial can opener and housing * Open shelving: * Drawers and cabinets storing clean dishes and other equipment * Cabinets, drawers, shelving holding/storing food A. Executive Director hired new dietary Manager. Dietary Manager and Maintenance director completed deep clean in main facility kitchen and in house 2 and 3 kitchens. The Executive Director created a schedule with sign off for deep cleaning ALL areas of concern, to be completed weekly. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. Kitchen Consultant or designee has done a walkthrough of all kitchen areas to include dry storage/pantry areas/ equipment and food storage areas and provided direction as to what to clean, replace, or repair. Executive director or designee will update the kitchen checklist to include all items identified on the survey for cleaning/sanitation and storage. * Dietary Manager and Maintenance Director cleaned inside and outside of reach in coolers, freezers. * Maintenance Director pressure washed outdoor storage space floors, walls, ceiling where refrigerators and freezers are stored, and the refrigerators and freezers.. The Executive Director created a schedule with sign off for the maintenance department to audit the need for pressure washing in ALL areas weekly and as needed. * Door thresholds to food storage areas cleaned, will be maintained by the maintenance department weekly and as needed for removal of dirt/debris. * Dietary Manager or designee will clean open shelving in dry storage and will be monitored daily for compliance by Dietary Manager or designee. Dietary Manager or designee will replace all shelving paper in drawers/cabinets. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. * Black plastic shelving was cleaned by Dietary Manager and will be monitored daily for compliance by Dietary Manager or designee, Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. * The floor of the pantry was cleaned by the Dietary Manager and will be monitored daily for compliance by the Dietary Manager. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. * The interior of microwaves were ALL cleaned and will be monitored daily for compliance by Dietary Manager, Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. * Industrial can opener and housing, was cleaned by Dietary Manager and will be monitored for cleanliness with each use by Dietary Manager or designee. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. * Dietary Manager cleaned open shelving and will be monitored daily for compliance by Dietary Manager or designee, Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. * The Dietary Manager cleaned the drawers and cabinets, storing clean dishes and other equipment and will be monitored daily for compliance by the Dietary Manager. Daily meeting with dietary manager and Executive Director to discuss compliance, changes and effectiveness. * Dietary Manager cleaned cabinets, drawers, shelving holding/storing food was cleaned and will be monitored daily for compliance by Dietary Manager or designee. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. * The Dietary manager or designee will bring the results of the above stated audits to QAPI monthly for 3 months or until deficient practice has resolved. The RD or designee will audit monthly to perform their kitchen sanitation and compliance audit monthly. Dietary Manager will bring results of the RD audit to QAPI monthly for 3 months or until deficient practice is resolved. b. The following areas were in need of repair: * Small holes in walls in kitchens. * Reach in refrigerator in house one not holding temperature at 41 degrees are below * Multiple exteriors of refrigerators with dirt and/rust on exteriors or with no handles * Multiple reach in refrigerators with large condensation and notable water leakage/build up * Microwave in house 2 with dents/damage * Flooring in house 3 with integrity flaws, chips, gouges yielding non-smooth surface * Multiple cupboards/cabinets/shelving with exposed porous wood and/or non-smooth surfaces. * Multiple refrigerators had water and/or excessive condensation in the refrigerators with water leakage/build up on shelves, food or beverage containers. B. Executive Director and Maintenance Director have completed a walkthrough of all kitchens identifying any holes in the walls, porous surfaces that are not cleanable, or other environmental factors needing repair and have a plan in place to repair these areas by compliance date. Daily meeting with maintenance director and Executive Director to discuss compliance, changes and effectiveness. * The Executive Director and Maintenance Director have completed a walkthrough of all kitchens identifying any holes, in the walls, needing repair and have a plan in place to repair these areas by compliance date. * House one reach in the refrigerator adjusted by the Facility Manager and holding proper temps. Temp checking as directed to be in sufficient compliance daily by Dietary Staff. * Will be repairing or replacing refrigerator units with rust or broken parts, Facility Manager to price and order replacements while Maintenance Director will price and order replacement parts.. The Maintenance Director has cleaned ALL units of dirt/debris/rust and will maintain cleanliness weekly and as needed. Oversight from the Executive Director weekly for compliance. * Facility Manager and Interim Dietary Manager have done a full House audit of all kitchens and freezers to assess for any build up, standing water or condensation and have put a plan in place to monitor for a continued issue and then will seek repair or replacement by compliance date. * Microwave in house 2 with dents/damage, has been removed. The facility manager has requested quotes for a commercial microwave to replace Microwave. Will be replaced by compliance date. * The Executive Director and Maintenance Director have completed a walkthrough of all kitchens identifying any flooring with integrity flaws, chips, gouges yielding non-smooth surface or other environmental factors needing repair and have a plan in place to repair these areas by compliance date. Quotes for labor to be obtained by the Maintenance Director and reported the Facility Manager. * Dietary Manger or designee will resurface all shelves and drawers to allow for cleanable surfaces by compliance date. * Facility Manager and Interim Dietary Manager have done a full House audit of all kitchens and freezers to assess for any build up, standing water or condensation and have put a plan in place to monitor for a continued issue and then will seek repair or replacement by compliance date. The Maintenance Director or designee will bring the results of the above stated audit to QAPI monthly for 3 months. c. Multiple food items found uncovered in reach in fridges. Multiple items without dates opened/prepared. Multiple items found past the manufactures use by dates and or facility date marking for use within 7 days. In house 3 a bag of hot dogs was observed that did not have a date and were visibly discolored and looked spoiled. A pan of dessert was loosely covered with plastic wrap where multiple areas of exposed food were noted. The pan of dessert was noted to have liquid contaminants from other areas of the fridge inside the food product where the open sections were. Staff was asked to discard the hot dogs and the dessert due to contamination and safety concerns. C. House 3, hotdogs and the pan of dessert were disposed of immediately. Dietary Manager or designee will monitor daily for dates opened/prepared and weekly for manufactures use by date. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. RD will hold an all-staff in-service for Dietary and Nursing staff on the following topics altered texture diets, kitchen cleanliness, Fridge/Food temps, dating and discarding foods, cooling and reheating food, covering food when in kitchen/Fridge, or taking out of the dining area to a resident, Substantial snacks, Infection control and glove use. d. Refrigerator in house 1 thermometer reading 48 degrees Fahrenheit on 08/15/25. Mayonnaise temperature was checked and found also at 48 degrees Fahrenheit. Multiple items were stored in the refrigerator and limited open space was observed potentially creating cold circulation concerns. Staff 2 (Cook) indicated some items in the fridge (near the back) were freezing. Staff 2 was instructed to check the temperature of all potentially hazardous foods and discard any found at greater than 41 degrees. Upon return to the facility on 08/18/25 the identified fridge was within acceptable temperatures (41 degrees) and was at maximum cold setting (7). D. The Dietary Manager tempted everything and disposed of items that did not meet temperature requirements. Refrigerator adjusted by the Facility Manager and holding proper temps. Temp checking as directed to be in sufficient compliance daily by Dietary Staff. e. Care giving staff were observed to not properly remove/change gloves and or wash hands when necessary during meals service on 08/18/25. Staff were observed to leave the kitchen with gloves on, touch residents and/or resident care equipment and return to the kitchen area without removing/changing gloves. Other staff were observed entering the kitchen from care areas and did not wash hands before donning gloves as required. E. Executive Director posting signage in all kitchens, with reminders for hairnets, aprons, process for hand washing and glove use. Dietary manager or designee will monitor for compliance and enforcement of safe processes. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. RD will hold an all-staff in-service for Dietary and Nursing staff on the following topics altered texture diets, kitchen cleanliness, Fridge/Food temps, dating and discarding foods, cooling and reheating food, covering food when in kitchen/Fridge, or taking out of the dining area to a resident, Substantial snacks, Infection control and glove use. Infection Preventionist or designee will audit week at different meals for hand hygiene and glove use. Infection Preventionist or designee will bring the results of the above stated audit to QAPI monthly for 3 months or until deficient practice has resolved. F. On 08/15/25 at 2:00pm already prepared food items were observed in the oven. Staff 2 was interviewed and revealed the food items were for dinner at 4:30 pm that day. On 08/18/25 at 12:30 pm, Staff 1 (Administrator) was interviewed and confirmed that on multiple days there was no evening cook to prepare dinner meals and that the morning cook prepared evening meals and care staff served the meal. Staff 1 acknowledged the food was being held hot for greater than 2 hrs on those days with no evening cook. Staff 1 and Staff 3 (Facility Representative) acknowledged that practice could impact food quality and palatability, having food continue the cooking process for that extended amount of time. F. Dietary Staff will now be prepping and plating all meals. The Executive Director has created a Dietary schedule that will allow for meals to be prepared and served prior to dinner rather than kept warm. Dietary Manager will hold a Dietary staff training on this process. Dietary Manger will hold an all Dietary department in service on all of the changes in the kitchen for compliance to include prepping and plating meals. The Executive Director or Designee will complete an audit weekly at different times of the day to ensure meals are plated, and served at scheduled meal times and proper diet is followed. The Executive Director will bring the results of these audits to QAPI for 3 months or until deficient practice has resolved. g. Pans of food were observed in house 3 not held on or in a heat source and no covers or lids during service to keep hot food hot or food protected from potential contamination. Pans of food were observed uncovered for more than 20 minutes. G. Executive Director has created a Dietary schedule that will allow for meals to be prepared and served prior to dinner rather than kept warm. Food warmers instituted and used by dietary staff to ensure that food temps are maintained at regulated temperature prior to and during the serving process. The Executive Director or designee will audit a meal weekly to ensure that residents are enjoying dignified dining, and that altered texture diets are followed as ordered. The Executive Director will bring the results of these audits to QAPI for 3 months or until deficient practice has resolved. h. Staff were observed in house 3 putting food off the stove in plastic containers for “left overs”. Staff were asked about proper cooling methods and what the time/temperature steps were for proper cooling. Staff was not able to correctly demonstrate knowledge of cooling or reheating temperatures/processes. H. RD will hold an all-staff in-service for Dietary and Nursing staff on the following topics altered texture diets, kitchen cleanliness, Fridge/Food temps, dating and discarding foods, cooling and reheating food, covering food when in kitchen/Fridge, or taking out of the dining area to a resident, Substantial snacks, Infection control and glove use. The Dietary Manager will be monitored daily for compliance by the Dietary Manager. Daily meeting with dietary manager and Executive Director to discuss compliance, changes and effectiveness. i. Facility had multiple residents on Mechanical soft diets. Staff were interviewed regarding items that are available to be provided to residents on mechanical soft diets. Varied answers were given. Staff did not have guidance to refer to in kitchen areas for appropriate foods for mechanical soft foods. Staff indicated they used to have a reference sheet to help them but didn’t know where it was. Multiple care staff indicated that they were the ones that would mechanicalize the food that the cook prepared for the residents and would “figure out” items as/if needed appropriate for the mechanical soft diet. Staff stated that if residents could not have a vegetable that was offered like lettuce for soft tacos, they would offer apple sauce or other fruit available. Staff 1 acknowledged that cook was not mechanicalizing food for mechanical soft diets. In house 3 a resident’s diet indicated Mechanical soft (ground) meat, resident was given cut up meat of various sizes/chunks none of which were ground. Vegetables on plate also included broccoli stems that were not fork mashable/soft. A whole roll with a hard/crusted bottom was also served. House 1 had a resident that was on mechanical soft on the list posted on the fridge however staff 4 (cook) was unaware any residents in that house were mechanical soft. Staff 1 was interviewed regarding the resident in house 1 on mechanical soft and indicated it was the resident’s preference to get a regular texture diet. Staff 1 acknowledged the diet order was still Mechanical soft and that the MD had not been informed of the resident’s preference to not follow mechanical soft diet. Staff 3 provided a typed sheet for Mechanical soft diets that included. “Tender meats (shredded or finely chopped), vegetables (soft, well cooked, pureed or smashed), breads (white bread, soft rolls or toast without crusts). None of the mechanical diets served for the lunch meal on 08/18/25 met criteria for mechanical soft. I. RCC or designee will reach out to all PCP of residents who are declining their altered texture diet and see if they would like to change the diet to regular texture. Diet cards to be made with all diet orders and preferences. The Executive Director posted Altered Texture directives in each Kitchen. RD will hold an all-staff in-service for Dietary and Nursing staff on the following topics altered texture diets, kitchen cleanliness, Fridge/Food temps, dating and discarding foods, cooling and reheating food, covering food when in kitchen/Fridge, or taking out of the dining area to a resident, Substantial snacks, Infection control and glove use. Dietary Staff will now be prepping and plating all meals. Dietary Manger will train all Dietary staff training on this process. The Executive Director or designee will audit a meal weekly to ensure that residents are enjoying dignified dining, and that altered texture diets are followed as ordered. The Executive Director or designee will bring the results of these audits to QAPI for 3 months or until deficient practice has resolved. j. On 8/15/25 staff 2 informed surveyor that dinner meal times were at 4 pm. When asked why dinner was at 4 pm, staff 2 indicated “it has just always been that way since I started.” Staff 2 acknowledged they felt 4 pm was early time for dinner. A care staff in house 3 indicated that dinner was at 4:30pm for their house. Surveyor inquired on why dinner was at 4:30 pm and they also did not know why and that “it has always been at 4:30 pm.” On 08/18/25 at 10:30 am staff 1 was asked about meal times and confirmed dinner is served at around 4:30 pm. They indicated they were not sure why it was 4:30 pm as it has been that way since they started. Staff 1 indicated most likely was because residents go to bed fairly early like 7 pm. Staff 1 indicated a snack was offered to residents if they wanted one but was not able to determine if it was a substantial snack indicating a protein source was given with the snack. Staff 1 acknowledged that dinner meal and breakfast meal was 16 hrs apart exceeding recommended maximum of 14 hrs. Staff 1 acknowledged that the facility could not determine or provide information that having dinner early with an extended time between meals was resident driven. J. Executive Director in coordination with the community and management has altered the mealtimes so that they will meet regulation and not exceed 14 hours between breakfast and dinner. Activity Director or designee will add a food Committee Component to the Monthly Resident Council meeting to encourage resident involvement in developing menus. The Executive Director or designee will audit a meal weekly to ensure that residents are enjoying dignified dining, that it is being provided at scheduled times, and that diets are followed as ordered. The Executive Director or designee will bring the results of these audits to QAPI for 3 months or until deficient practice has resolved. k. Staff food storage items were observed stored in house 3 with resident food. Staff acknowledged that was their food and that there was a space for staff to store their food and should not be stored in with resident food items. K. Staff Fridges ordered and will be placed in each house. l. On 08/15/25 at 2:38 a plate of food was observed sitting on the counter in house 3. Staff verified this was a plate of food for a resident from lunch. Staff indicated lunch was served at about 11:30 am. L. Dietary Staff will now be prepping and plating all meals. Dietary Manager will train all Dietary staff training on this process. The Executive Director or designee will audit a meal weekly to ensure that residents are enjoying dignified dining, that it is being provided at scheduled times, and that diets are followed as ordered. The Executive Director or designee will bring the results of these audits to QAPI for 3 months or until deficient practice has resolved. m. On 08/15/25 at approximately 3:00pm a nonstaff member was observed in the house 2 kitchen. It was later determined this was a family member of a resident. This person was observed to be heating up some food brought in for the resident. The family member was using kitchen items/equipment and did not have a hair restraint and was not observed to wash hands. Family member did not check the temperature of the food warmed for resident to determine if reheated to correct safe temperatures. Facility staff was in the kitchen area with family member and surveyor. M. Executive director or designee will distribute a letter to family on how to get food reheated by the staff when needed rather than entering the kitchen. n. House 2 had a carpet/floor cleaning machine stored where food is prepared, stored, and served. Staff 1 acknowledged that piece of equipment should not be stored in the kitchen area. N. This was moved and properly stored immediately. o. The reach-in refrigerator located in the outdoor covered storage area was noted to have raw ground beef stored above pork(bacon) which is not according to proper storage of raw meat products. O. Executive Director posted proper food storage processes on all refrigerators within the community. Dietary manager to monitor for compliance and adjust storage areas as necessary. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. p. Registered dietitian reports for July documented concerns for dating of foods, food being out of date, cleanliness, concerns with hand hygiene and glove use, staff not following diets, improper meat storage and resident complaints on food quality. P. The RD or designee will audit monthly during meal prep to ensure the proper diet textures are being prepared as well as perform their kitchen sanitation and compliance audit monthly. Executive Director and Dietary Manager will discuss Kitchen sanitation and compliance daily via stand-up meeting to include reviewing the food/fridge/freezer temps, and cleaning checklist.

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, record review, and interview, it was determined that 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. The facility also failed to ensure that therapeutic diet texture orders for residents were followed. This is a repeat citation. Findings include, but are not limited to: Observations of the main kitchen in House 1 and the kitchen areas in Houses 2 and 3 were conducted on 11/24/25 from 12:05 pm through 2:40 pm. The following was identified: 1. Staff 5 (Cook) reported there was one resident in the facility who required a mechanical soft diet. Staff 4 (Dietary Manager) reported that there were two residents who required a mechanical soft diet. Staff 4 and Staff 5 gave different answers regarding how food items on the menu were to be prepared for these residents. Neither of the cooking staff knew of a diet manual with instructions for preparing therapeutic diet textures. Staff 4 reported that she cooks the vegetables very soft for residents on mechanical soft diets. At approximately 1:30 pm the surveyor tested the asparagus that had been served at lunch for softness. The surveyor was unable to cut into the 1”-1 ½” pieces with the side of the large metal serving spoon. Staff 6 (Interim Administrator) provided the signed physician’s orders indicating both residents had the same mechanical soft diet order. She acknowledged the list of resident diet orders should be easily accessible to the kitchen staff, as well as the diet manual with instructions on the preparation of therapeutic diets. Staff 6 also acknowledged that fibrous vegetables, such as asparagus, were not fork-mashable and not appropriate for a mechanical soft diet. 2. The kitchen in House 2 did not have an operable dishwasher, and staff were handwashing all resident dishware. Staff 10 (CG), who acknowledged doing the dishes after breakfast, and Staff 11 (Housekeeping), who was observed doing dishes after lunch, did not know that the sanitizer water needed to be tested for chemical concentration. No sanitizer test strips were available in House 2. Staff 4 brought sanitizer test strips from House 1 and tested the sanitizer water being used to wash lunch dishes. The sanitizer water chemical strength was zero. 3. The following areas needed repair: a. The refrigerator in House 1 had a damaged seal, which made the door difficult to open. A large amount of condensation was present on the inside, including notable water dripping down from the top. b. The microwave in House 2 had dents/damage and areas with rust. On 11/24/25 at 2:40 pm, these areas were reviewed with Staff 6 and Staff 7 (Administrator in Training). They acknowledged the findings.

OAR 211-054-0030 (1)(a) Food Sanitation Rules OAR 333-150-000 All residents are at risk for this deficient practice. An In-Service will be held by the RD on Altered Texture diets with Dietary Staff and Health Services Staff to include education and observation of the Mech soft diets being prepared and plated. ED or designee will ensure that there is a Diet Manual available for staff to be able to reference when preparing therapeutic diet texture. The Dietary Manager or designee will Inservice staff on the Diet Manual and that it is a guide and reference for preparing meals that deviate from a regular diet. Dietary Manager or designee will Ensure that there is a current diet list posted in all kitchens at all times as well as a Diet Manual in House 1 at all times for reference. The ED or designee will audit meal preparation of altered texture diets at different mealtimes weekly to ensure that the diet follows the diet order and is prepared according to the diet manual. The ED or designee will bring the results of the above audit to QAPI monthly for three months or until the deficient practice has been resolved. The ED or designee will audit to ensure that a current diet list is posted in all kitchens daily during rounds. The ED or designee will bring the results of the above audit to QAPI monthly for three months or until the deficient practice has been resolved. An In-service will be held by the RD on proper sanitation of dishwashing, and how to properly test the sanitation water. Dietary Manager or designee will ensure that there are the proper sanitation testing materials available in all houses at all times. The Dietary Manager or designee will perform random audits weekly during different mealtimes to ensure dietary staff and health services staff are performing proper sanitation testing as needed during the dishwashing process. The Dietary Manager or designee will bring the results of the above audit to QAPI for three months or until the deficient practice has resolved. The refrigerator in House 1 was replaced with a new Microwave. The Microwave in House 2 was replaced with a new Microwave. The Maintenance Director or designee will perform a Kitchen Audit weekly to ensure that equipment is functioning and in proper working order weekly. The Maintenance Director or designee will notify the ED or designee of items requiring repair or replacement. The Maintenance Director or designee will bring the results of the above audit to QAPI monthly for three months or until the deficient practice has resolved.

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 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.

OAR 211-054-0030 (1)(a) Food Sanitation Rules OAR 333-150-000 All residents are at risk for this deficient practice. An In-Service will be held by the RD on Altered Texture diets with Dietary Staff and Health Services Staff to include education and observation of the Mech soft diets being prepared and plated. ED or designee will ensure that there is a Diet Manual available for staff to be able to reference when preparing therapeutic diet texture. The Dietary Manager or designee will Inservice staff on the Diet Manual and that it is a guide and reference for preparing meals that deviate from a regular diet. Dietary Manager or designee will Ensure that there is a current diet list posted in all kitchens at all times as well as a Diet Manual in House 1 at all times for reference. The ED or designee will audit meal preparation of altered texture diets at different mealtimes weekly to ensure that the diet follows the diet order and is prepared according to the diet manual. The ED or designee will bring the results of the above audit to QAPI monthly for three months or until the deficient practice has been resolved. The ED or designee will audit to ensure that a current diet list is posted in all kitchens daily during rounds. The ED or designee will bring the results of the above audit to QAPI monthly for three months or until the deficient practice has been resolved. An In-service will be held by the RD on proper sanitation of dishwashing, and how to properly test the sanitation water. Dietary Manager or designee will ensure that there are the proper sanitation testing materials available in all houses at all times. The Dietary Manager or designee will perform random audits weekly during different mealtimes to ensure dietary staff and health services staff are performing proper sanitation testing as needed during the dishwashing process. The Dietary Manager or designee will bring the results of the above audit to QAPI for three months or until the deficient practice has resolved. The refrigerator in House 1 was replaced with a new Microwave. The Microwave in House 2 was replaced with a new Microwave. The Maintenance Director or designee will perform a Kitchen Audit weekly to ensure that equipment is functioning and in proper working order weekly. The Maintenance Director or designee will notify the ED or designee of items requiring repair or replacement. The Maintenance Director or designee will bring the results of the above audit to QAPI monthly for three months or until the deficient practice has resolved.

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 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 main facility kitchen and house 2 and 3 kitchen areas were reviewed on 1/25/24 from 11:30 am through 2:30 pm and found the following:   a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:   * Inside and outside of reach in coolers and freezers; * Fans blades, cages and screen of open window in house 1; * Ceiling vents; * Walls; * Interior of microwaves; * Interior of ovens; * Industrial can opener housing; * Underneath, between and behind equipment; * Floor mats: * Kitchen floors; * Open shelving: * Drawers and cabinets; * Metal legs of tables/prep spaces; * Interior and exterior of Rubbermaid drawers; and * Drains under sinks.   b. The following areas were in need of repair:   * Small holes in walls throughout kitchens; * Reach in refrigerator with large crack in drawer; * Significant floor damage under sink in Kitchen 2: * Multiple cupboard/cabinets/shelving with exposed porous wood; * Window seal in house 1 kitchen with non smooth surface for cleaning; * Countertops with visible damage and signs of ware in multiple areas; * Dining room chairs with un-smooth surfaces with damage to outer layer of seating surfaces; c. Multiple sauté pans were observed with visible damage of nonstick surface. Plastic cups, mugs, bowls were noted with pitting and glaze worn yielding un-smooth surfaces. d. Multiple plastic spatulas or other utensils were found in poor repair being heavily melted, scored, stained and/or with chunks missing. Multiple hot pads found with holes. e.  Multiple items found in reach in refrigerators without date and/or resident identifiers. Multiple items found past the manufactures use by dates and or facility date marking for use within 7 days. f. Refrigerator in dining room of house 1 without thermometer to ensure items stored at appropriate temperatures. g. Multiple dry good items stored unsecured and open to possible contamination. Other dry goods not dated when opened or manufactures use by date marked on item when removed from packaging. Some bulk food items found with scoops stored inside. h. Care giving staff were not wearing aprons during meal service to create a clean barrier as a mechanism to prevent possible spread of infectious agents. i. Dry good storage was noted to have stock stored on the floor. Staff 3 (Person in Charge/PIC) acknowledged s/he had not had a chance to put away stock yet.  Stock was delivered greater than 24 hrs prior. Upon interview it was determined PIC was also the primary maintenance worker for the facility. Staff 3 acknowledged that maintenance duties were taking away from time for cleaning and organizing food storage according to food code. Staff 3 (Cook/PIC) toured kitchen areas with surveyor and acknowledged the findings. On 1/25/24 at approximately 1:15 pm, the surveyor reviewed the above areas with Staff 1 (Executive Director) and Staff 2 (Administrator) who acknowledged the identified areas.

C240 1. All of the listed items have been or are in process of being deep cleaned: * Inside and outside of reach in coolers and freezers; * Fans blades, cages and screen of open window in house 1; * Ceiling vents; * Walls; * Interior of microwaves; * Interior of ovens; * Industrial can opener housing; * Underneath, between and behind equipment; * Floor mats: * Kitchen floors; * Open shelving: * Drawers and cabinets; * Metal legs of tables/prep spaces; * Interior and exterior of Rubbermaid drawers; and * Drains under sinks. The following items have been or are being repaired: * Small holes in walls throughout kitchens; * Reach in refrigerator with large crack in drawer; * Significant floor damage under sink in Kitchen 2: * Multiple cupboard/cabinets/shelving with exposed porous wood; * Window seal in house 1 kitchen with non smooth surface for cleaning; * Countertops with visible damage and signs of ware in multiple areas; * Dining room chairs with un-smooth surfaces with damage to outer layer of seating surfaces; These items have been discarded and new ones purchased: c. Multiple sauté pans d. Multiple plastic spatulas, other utensils and hot pads in poor repair are ordered and being replaced. e. All undated food and expired food has been discarded. f. Thermometer purchased for the refrigerator in dining room of house 1 g. All dry good items will be stored in secure bins to ensure that they are free from contamination. All dry goods without open dates have been discarded. Expired dry goods have been discarded. The scoops are no longer stored in the bins. h. Aprons have been ordered and caregiving staff have all been trained to wear aprons during meal service to create a clean barrier as a mechanism to prevent possible spread of infectious agents. i. Additional staff have been hired to relieve PIC and to ensure that all food and supplies are put away immediately and are not on the floor according to food code. 2. All staff will go through training on proper cleaning, food storage, and infection prevention control. All supplies will be closely monitored to ensure they are in good repair, and if not, will be discarded immediatley. Kitchen cleaning task sheets are being implemented immediately. 3. Daily walk throughs and weekly monitoring of Kitchen Book w/temps, task sheets, etc. 4.The Dietary Manager and the Executive Direcor

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair, ensure menus were made available to all residents, and prepare and serve food in a sanitary manner in accordance with 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 and dining room in House 1, and Houses 2 and 3 kitchen and dining areas were made on 10/24/24 from 10:45 am through 2:45 pm. The following was identified:   a. The following areas were in need of repair:   * Multiple cupboard/cabinets/shelving had exposed porous wood; * Windowsill in House 1 kitchen had non-smooth surface for cleaning; * Countertops had visible damage and signs of wear in multiple areas; * Dining room chairs had un-smooth surfaces with damage to outer layer of seating surfaces. b.  Multiple items were found in refrigerators without facility date marking for use within 7 days. c. Multiple items were found in refrigerators, identified by staff as for specific residents, without dates or resident identifiers. d. Multiple items, identified by staff as belonging to staff members, were found on refrigerator shelves alongside food and beverages for residents. Some of the staff food and beverages had been partially consumed. e. Refrigerator on the deck of House 2 did not have a thermometer to ensure items were stored at appropriate temperatures. Staff 3 (Dietary Supervisor) reported in an interview that the refrigerator had been donated to the facility two days previously and a thermometer was being delivered in the next 1-2 days with the next supply delivery. A thermometer from another refrigerator was placed in this refrigerator during survey and Staff 3 was instructed to recheck in a few hours to ensure the refrigerator was at the appropriate temperature. Upon inspection of the freezer on top of this refrigerator unit, the foods were found to not be frozen, including a 3 gallon drum of ice cream. Staff 3 was instructed to throw away all items in the freezer. f. Care giving staff were not wearing aprons during meal service to create a clean barrier as a mechanism to prevent possible spread of infectious agents. g. Staff members preparing food did not have hair restrained. i. A menu for the current week was not available to residents in Houses 2 and 3. Multiple staff members reported the menu was typically posted on the bulletin board in the dining room, but they had not seen one for the current week. Staff 3 acknowledged the current week menu had not been made available to residents. These findings were discussed with Staff 3 throughout the day and reviewed with Staff  2 (Executive Director) and Staff 3 at 2:30 pm.  They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? 1. All listed items have/are in the process of being repaired or replaced: ? Cabinets, cupboards and shelving with exposed porous wood, all Houses. ? Windowsill in House 1 non-smooth surface for cleaning. ? Countertops with visible damage and signs of wear all Houses. ? Dining room chairs with un-smooth surfaces and damage to the outer layer of seating surface all Houses. ? Will be replacing the refrigerator/freezer, non-working unit removed. ? Marking facility date, for use within 7 days. ? All resident food items will be dated with open/expiration date and resident identifier.   ? All staff food items will be placed in a designated refrigerator for staff with an open/expiration date and staff identifier.   ? Weekly menus will be posted in designated areas with alternative menu. Copy of weekly menu and alternative menu will be offered to each resident. ? Aprons readily available for all staff, prior to entering the kitchen area. Education with documentation of date, training and sign off. ? Hairnets readily available for all staff, prior to entering the kitchen area. Education with documentation of date, training and sign off. 2. All-Staff Meeting will be held to review Kitchen Binder: Cleaning schedule- ways to identify and report uncleanable surfaces, Food Safety/Handling: Proper labeling, wearing of hairnets, beard nets, and aprons. Monitoring will occur regularly. 3. We will monitor with daily spot checks and weekly audits. 4. The RCC, Dietary Manager, Executive Director and Regional Director will be responsible for monitoring. ?????

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair, ensure menus were made available to all residents, and prepare and serve food in a sanitary manner in accordance with 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 and dining room in House 1, and Houses 2 and 3 kitchen and dining areas were made on 02/20/25 from 1:45 am through 3:45 pm. The following was identified:   a. The following areas were in need of repair: * Multiple cupboard/cabinets/shelving had exposed porous wood. * Reach in refrigerator on the patio of House 2 had cracks/chips in the plastic areas along with the refrigerator was rusted along the entire outer door and was not holding temperature at 41 degrees or below as required. b. The following items were needing cleaning; * Multiple drawers, cabinets, and cupboards in the kitchen area in House 3 had food spills, crumbs, dirt and debris. * Reach in refrigerator in House 3 had visible accumulation of liquid spills, food debris and dirt under the pull out drawers. * Reach in refrigerators on the patio of House 2 had dirt/food debris/dust build up/ black/grey debris around the edges of door frames and door seals. c.  Multiple items were found in refrigerators without facility date marking for use within seven days. Multiple potentially hazardous food items were observed opened and did not contain open dates as required per rule. c. Multiple items were found in refrigerators, identified by staff as for specific residents, without dates or resident identifiers. Reach in refrigerator in House 2 dining room contained a container of store/restaurant bought pancakes that had no identifiers, no date, and had an accumulation of visible mold growth on the food product. d. A reach in refrigerator in House 1 kitchen had a carton of whole shell eggs stored directly above ready to eat foods with no barrier to prevent possible spill/drip contamination to the packages of the RTE food items below. House 2 reach in refrigerator on the patio had boxes of raw chicken stored directly next to boxes of bacon. Raw chicken boxes were overlapping bacon boxes and posed a potential for cross contamination of products that have different cook to temperatures. e. Refrigerator on the deck of House 2 did not have a thermometer to ensure items were stored at appropriate temperatures. Two cases of heath shakes were stored in the refrigerator. The boxes were marked "Keep Frozen". The health shakes were all in liquid form. Surveyor used thermometer to test the temperature of the refrigerator and it was found at 44 degrees. Staff 2 (Dietary Supervisor) was not aware that the health shakes were required to be stored frozen and that the use by date on the cartons was in the frozen state. Staff 2 was also unaware that the shakes were to be used within 14 days of thawing. Staff 2 was able to confirm those cartons were on that weeks shipment and that they would be used within the next seven days. Surveyor checked the temperature of the health shakes and they were at 37 degrees and they were moved to an alternate location to ensure proper temperature control. f. Residents did not have access to the current weeks menus in Houses 2 and 3. Staff 2 acknowledged there was no weekly menu posted in House 2 and the incorrect/previous weeks menu posted in House 3. Staff 3 verified the correct/current weeks menus were available in the house kitchens in a binder and posted the menus at that time. Staff 2 toured the kitchen areas with the surveyor and acknowledged the identified areas. At 3:30 pm the findings were reviewed with Staff 1 (Administrator) who acknowledged the areas.

All listed items below are/have been replaced/repaired/purchased or moved: * Cupboards/cobinets/shelving with exposed porpus wood. (being update with material that provides a cleanable surface) * Refridgerator H2 (not same as freezer from initail visit) being replaced. * Thermometer purchesed * All eggs moved to bottom shelf * Raw meats moved/seperated to prevent potential cross contamination while being stored. Items listed below have been added to daily task sheets. To be monitored for compliance by dietary manager 3x weekly. * Drawers, cabinates, cupboards cleaned/wiped out. * Wipe out inside/ouside of refridgators (including under the drawers. * Items found without date marking use in 7 days. * Items found in refidgerator without dates and identifiers for staff or residents. * Access to resident menues in Houses 2/3. All items listed below reviewed with staff via ALL staff meeting 2/25/25: *Importance of having a clean enviornorment, dating all items with experation date * List of experation date durations posted in each kitchen. *

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in good repair, and prepare and serve food in a sanitary manner in accordance with 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 and dining room in House 1, and Houses 2 and 3 kitchen and dining areas were made on 04/15/25 from 10:15 am through 11:30 am. The following was identified:   a. The following areas were in need of repair: * Large hole/damage to wall behind the door in the kitchen of house 2 * Large area in ceiling above the reach in refrigerator with water damage, paint and ceiling peeling/cracking. b. The following items were needing cleaning; * Reach in refrigerators and/or freezers in house 1, house 2 and house 3 c.  Multiple items were found in refrigerators without facility date marking for use within seven days. Multiple potentially hazardous food items were observed opened and did not contain open dates as required per rule. d. Multiple items were found in refrigerators, identified by staff as for specific residents, without dates or resident identifiers. Multiple food items were found past seven days or were observed without dates but with noticeable decomposition indicating they were well past seven days or not safe for consumption. e. Refrigerator in house one thermometer was checked at 10:30 am and was found at 50 degrees Fahrenheit. Staff 2 indicated the facility had just been putting away stock about one hour before. Surveyor placed their thermometer in the refrigerator and when checked at 11:00 am both the facility thermometer and the surveyor's thermometer both read well above 41 degrees at 50 degrees and 51.5 degrees respectively. A food item was checked and the temperature was at 49.3 degrees. Facility logs were reviewed and no temperature was documented for that refrigerator for that morning. Staff 1 (Administrator) and Staff 2 (Dietary Manger) were instructed that any potentially hazardous non shelf stable food products stored in that refrigerator that were found above 41 degrees would need to be discarded. Staff 1 and Staff 2 voiced understanding. f. Opened package of hard boiled eggs were not closed and were stored open to potential contamination. There was no date opened on the package. Multiple items were observed in reach in refrigerators that did not have a label of what the food product was and the product was not clearly identifiable. Staff 1 and 2 toured the kitchen areas with the surveyor and acknowledged the continued areas not in accordance with food sanitation rules that were identified.

(A) The following areas were in need of repair; * Large hole/damage to wall behind the door in the kitchen of house 2        oRepaired and new door stopper installed. * Large area in ceiling above the reach in refrigerator with water damage, paint and ceiling peeling/cracking.        o Area has been inspected, repaired and repainted. (B)  The following items were needing cleaning; * Reach in refrigerators and/or freezers in house 1, house 2 and house 3        o Tasks ares part of cleaning task sheets and will be monitored for compliance by Excutive Director and/or Dietary Manager daily. (C) Multiple items were found in refrigerators without facility date marking for use within seven days. Multiple potentially hazardous food items were observed opened and did not contain open dates as required per rule. (D) Multiple items were found in refrigerators, identified by staff as for specific residents, without dates or resident identifiers. Multiple food items were found past seven days or were observed without dates but with noticeable decomposition indicating they were well past seven days or not safe for for residents.         o New labeling process. Labels will be placed upon arrivel. Once item is pulled/opened, label will be filled out with identifier/date open/use by date. This process will address C, D and F . Dietary Manager and Excutive Director to check daily for proper labeling.                            o Training to be provided to all staff on new process. (E) Refrigerator in house one thermometer was checked at 10:30 am and was found at 50 degrees Fahrenheit. Staff 2 indicated the facility had just been putting away stock about one hour before. Surveyor placed their thermometer in the refrigerator and when checked at 11:00 am both the facility thermometer and the surveyor's thermometer both read well above 41 degrees at 50 degrees and 51.5 degrees respectively. A food item was checked and the temperature was at 49.3 degrees. Facility logs were reviewed and no temperature was documented for that refrigerator for that morning. Staff 1 (Administrator) and Staff 2 (Dietary Manger) were instructed that any potentially hazardous non shelf stable food products stored in that refrigerator that were found above 41 degrees would need to be discarded. Staff 1 and Staff 2 voiced understanding.              o All items were disposed of. Tempature monitoring was done for 48hrs before restalking to ensure tempature was maintaining. Once restocked no further issues have been noted. (F) Open package of hard boiled eggs was not closed and were stored open to potential contamination. There was no date opened on the package. Multiple items were observed in reach in refrigerators that did not have a label of what the food product was and the product was not clearly identifiable.             o New labeling process. Labels will be placed upon arrivel. Once item is pulled/opened, label will be filled out with identifier/date open/use by date. This process will address C, D and F . Dietary Manager and Excutive Director to check daily for proper labeling.       o Training to be provided to all staff on new process. Monthly RD oversight to ensure compliance for at minimum 90 days.

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 C240

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

Refer to C240

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

Refer to C240

Based on observations, interviews and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C150, C240 and C455.

Refer to C 150 and C 240.

Based on observations and staff interviews, it was determined the facility administration failed to provide necessary oversight of the food service program to achieve and maintain compliance with food sanitation rules. Findings include, but are not limited to: On 04/15/25 at 10:15 am, a revisit kitchen survey was conducted which found multiple areas that remained out of compliance. This was the third failed revisit for the kitchen survey. At 11:15 am, Staff 1 (Administrator) and Staff 2 (Dietary Manager) acknowledged the need for enhanced oversight of the kitchens and food service program.

*Based on observations and staff interviews, it was determined the facility administration failed to provide necessary oversight of the food service program to achieve and maintain compliance with food sanitation rules. Findings include, but are not limited to: On 04/15/25 at 10:15 am, a revisit kitchen survey was conducted which found multiple areas that remained out of compliance. This was the third failed revisit for the kitchen survey. o New labeling and cleaning processes put in place, several trainings provided on new processes. Daily oversight from Executive Director and Dietary Manager for compliance. Monthly RD oversight to ensure compliance for at minimum 90 days.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240.

Refer to C240

Based on observations and interviews, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 240.

Refer to C240

Based on interview, observation and review of records, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 240.

Refer to C 240.

The findings of the kitchen inspection, conducted 01/25/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first re-visit to the kitchen inspection of 01/25/24, conducted 10/24/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 01/25/24, conducted 02/20/25, 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, Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities. 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 third revisit to the kitchen inspection of 01/25/24, conducted 04/15/25, 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, Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities. Tag numbers beginning with the letter 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. 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 fourth re-visit to the kitchen inspection of 01/25/24, conducted 06/06/25, 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, Oregon Health Service Food Sanitation Rules OARs 333-150-0000, and OARs 411 Division 57 for Memory Care Communities.

Based on interview and record review, it was determined the facility failed to immediately investigate injuries of unknown cause to rule out abuse or suspected abuse and failed to report the incident to the local Seniors and People with Disabilities (SPD) office if abuse or suspected abuse could not be ruled out for 1 of 1 sampled resident (#3) who experienced an injury of unknown cause. Findings include, but are not limited to: Resident 3 admitted to the facility in 05/2021 with diagnoses including rheumatoid arthritis. Interviews with staff and review of Resident 3's clinical records including progress notes, outside service provider notes (hospice), service plans, temporary service plans and evaluations dated 10/22/22 through 01/19/23 revealed the following: During the acuity interview on 01/23/23, the facility identified Resident 3 had high ADL care needs, was dependent on staff for most ADL care and required use of a mechanical lift and two staff to assist with transfers. The service plan dated 11/28/22, identified Resident 3 was incontinent of bowel and bladder and required staff to provide total assistance with incontinent care. In a progress note dated 12/11/22, staff documented a "skin issue Res has bruising in R groin crease. Be cautious not to pull brief too tightly to avoid further bruising." There was no documented evidence the facility investigated the cause of the bruise or ruled out abuse or suspected abuse and there was no documented evidence the facility reported the incident to the local SPD office. During an interview on 01/24/23, Staff 1 (ED) stated there was no incident report or investigation documented in Resident 3's record related to the bruise noted on 12/11/22. The need to ensure injuries of unknown cause were immediately investigated and reported to the local SPD office if abuse or suspected abuse could not be ruled out was discussed with Staff 1, Staff 3 (RCC) and Staff 4 (VP of Management Services) on 01/24/23. They acknowledged the findings and reported the incident to the local SPD office per the survey team's request. The facility provided confirmation of the report prior to exit.

What actions will be taken to correct the rule violation? Incident was reported to local APD. · How will the system be corrected so this violation will not happen again? In-service to be held regarding proper procedure for abuse reporting, incident report completion and temporary service plan/alert charting. · How often will the area needing correction be evaluated and who is assigned to evaluating the changes? The progress notes will be reviewed weekly, Incident reports each business day, and TSPs each business day. · Who on your staff will be responsible to see that all the corrections are completed and monitored? The RCC and Executive Director will be responsible.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair and food preparation procedures were in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: The main kitchen in House 1 and the kitchens in Houses 2 and 3 were toured on 01/23/23 and 01/24/23. 1. The following was identified to need cleaning and/or repair: * In House 1 the dry storage room shelving had peeling paint throughout and a 2" strip of brown debris along all the edges; * In House 2 the countertops were worn, exposing the undersurface, creating an uncleanable surface; * In Houses 1 and 3 the black rubber mat in front of the sink had food embedded in multiple areas; and * In all three houses the paint was chipping off the cabinetry, exposing bare wood and creating an uncleanable surface. 2. The garbage cans in all 3 kitchens were observed to not be covered. The above areas were discussed with Staff 1 (ED) during a walk-through of the kitchens on 01/26/23. She acknowledged the findings.

What actions will be taken to correct the rule violation? All areas of concern are being addressed, parts ordered, etc. Maintenance Director working on corrections. · How will the system be corrected so this violation will not happen again? Regular walk throughs will be performed to observe environmental concerns by the Maintenance Director as well as the Executive Director · How often will the area needing correction be evaluated and who is assigned to evaluating the changes? Maintenance Director will review each working day and report to Executive Director. Both the Maintenance Director and Executive Director will do weekly walk throughs together. · Who on your staff will be responsible to see that all the corrections are completed and monitored? The Executive Director will ensure walk throughs are occurring and areas needing addressed are taken care of.

Based on observation, interview and record review, it was determined the facility failed to ensure residents' short-term changes of condition were monitored consistent with the residents' evaluated needs with weekly progress noted until conditions resolved for 2 of 2 sampled residents (#s 2 and 3) who experienced short-term changes of condition. Findings include but are not limited to: 1. Resident 3 admitted to the facility in 05/2021 with diagnoses including rheumatoid arthritis. Interviews with staff and review of Resident 3's clinical records including, progress notes, outside service provider notes (hospice), service plans, temporary service plans and evaluations dated 10/22/22 through 01/19/23 revealed the following: During the acuity interview on 01/23/23, the facility identified Resident 3 had high ADL care needs and was dependent on staff for most ADL care and required use of a mechanical lift and two staff to assist with transfers. The service plan dated 11/28/22, identified Resident 3 was incontinent of bowel and bladder and required staff to provide total assistance with incontinent care. The following short-term changes of condition were documented in Resident 3's progress notes: * On 10/22/22, staff documented "while changing resident, med aide noticed the resident's red raised area on both buttocks had increased in diameter and the top layer of skin on the red area was rubbing off with gentle touch". The med aide cleaned and treated the area with barrier cream. "Med aide continue to monitor."; * On 12/01/22, staff documented "During the 0500 incontinence check an open sore on [his/her] Sacral dimple was found to be red all around the area and bleeding slightly, no pain currently. Report to the Med Tech the following: Watch for more redness, swelling, pain and bleeding or any signs of infection". The caregiver "cleaned the area and placed barrier cream on the sore."; * On 12/11/22, staff documented "skin issue Res has bruising in R groin crease. Be cautious not to pull brief too tightly to avoid further bruising."; and * On 12/13/22, staff documented "Res had been scratching the R groin crease which was red and moist w/ odor. [Resident 3] tore a mole in the area, which caused it to start bleeding. Area no longer bleeding, cleaned and applied barrier cream, res states relief. Keep area clean and dry and apply barrier cream. Document any bleeding or changes." There was no documented evidence the facility monitored Resident 3's skin conditions and bruise consistent with the resident's evaluated needs or noted weekly progress of the skin conditions and bruise until the conditions resolved. During an interview on 01/24/23, Staff 5 (MT) stated "all previous skin break down had healed" and staff provided frequent repositioning, frequent incontinent checks, and applied barrier cream with incontinent care to try to prevent skin breakdown. The need to ensure residents' short-term changes of condition were monitored consistent with the residents' evaluated needs, with weekly progress noted until conditions resolved was discussed with Staff (1 ED), Staff 3 (RCC) and Staff 4 (VP of Management Services) on 01/24/23. They acknowledged the findings. 2. Resident 2 admitted to the facility in 11/2022 with diagnoses including dementia. Review of Resident 2's clinical record revealed the following: On 12/05/22, Resident 2 experienced an unwitnessed non-injury fall. The facility placed Resident 2 on alert charting and implemented a non-skid mat under a fall mat to minimize further occurrences of falls. A progress note on 12/13/22 indicated Resident 2 sustained a delayed bruise as a result of the fall. On 01/05/23, a progress note indicated Resident 2 was being removed from alert charting for the fall. There was no documented evidence of weekly progress noted until the condition was determined resolved. On 01/25/23, the need to ensure resident specific interventions were documented weekly with progress noted until changes of condition were resolved was discussed with Staff 1 (ED). She acknowledged the findings.

What actions will be taken to correct the rule violation? All TSPs and progress notes reviewed to ensure proper documentation being done. ED/LPN will be making weekly notes on all temporary and significant change of conditions. Staff training provided on TSPs, Incident Reports as well as daily documentation. · How will the system be corrected so this violation will not happen again? The Executive Director/LPN will review TSPs and progress notes weekly, as well as ensure that she provides a weekly nursing note on all short term and significant changes of conditions. · How often will the area needing correction be evaluated and who is assigned to evaluating the changes? Daily review of TSPs and Incident Reports by the RCC and ED, Weekly progress notes review and documentation by the ED. · Who on your staff will be responsible to see that all the corrections are completed and monitored? The Executive Director

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month, fire drill records included documentation of all required elements and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Review of fire and life safety records for August 2022 through January 2023 identified the following deficiencies: 1. There was no documented evidence of fire drills conducted every other month. 2. The facility was not relocating residents during fire drills so there was no documentation of location of simulated fire origin, the escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, number of occupants evacuated, and evidence alternate routes were used. 3. There was no documented evidence of fire and life safety instruction provided to staff on alternate months. These findings were reviewed with Staff 1 (ED) and Staff 9 (Maintenance) on 01/25/23 at 2:45 pm. They acknowledged the need to document all required components on fire drills conducted every other month and implement fire and life safety instruction to staff on alternate months.

What actions will be taken to correct the rule violation? Fire Drill forms reviewed and Maintenance Director instructed on appropriate documentation as well as instruction on how to evacuate. Fire Safety training done at the all staff meeting. · How will the system be corrected so this violation will not happen again? All Fire Drills/Evacuations will be documented. The Maintenance Director will then turn the form into the Executive Director who will determine if all of the required information is there and then sign off if so. If not, the drill will be re-done in the same month. · How often will the area needing correction be evaluated and who is assigned to evaluating the changes? Drills and Fire Life Safety will be reviewed monthly. · Who on your staff will be responsible to see that all the corrections are completed and monitored? The Maintenance Director and Executive Director

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 01/23/23. The following deficiencies were identified: * The doors throughout Houses 1 and 3 had multiple patches of finish that were worn off; * Multiple door frames throughout Houses 1 and 3 had scratches and gouges; * The handrails throughout Houses 1 and 3 had scratched paint; and * The sliding glass door runner in House 1 had black debris buildup along length of runner. The areas needing cleaning and/or repair were reviewed with Staff 1 (ED) on 01/26/23. She acknowledged the items needing cleaning or repair and reported the doors and door frames were being repaired soon.

What actions will be taken to correct the rule violation? All doors in house 1 and 3 will be painted and repaired. · How will the system be corrected so this violation will not happen again? Regular walk throughs will be performed to observe environmental concerns by the Maintenance Director as well as the Executive Director · How often will the area needing correction be evaluated and who is assigned to evaluating the changes? Maintenance Director will review each working day and report to Executive Director. Both the Maintenance Director and Executive Director will do weekly walk throughs together. · Who on your staff will be responsible to see that all the corrections are completed and monitored? The Executive Director will ensure walk throughs are occurring and areas needing addressed are taken care of.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system for security purposes to alert staff when residents exit the RCF and failed to provide a functional call system that connected resident units to the care staff. Findings include, but are not limited to: 1. The interior of the facility was toured on 01/23/23. House 1, an unsecured RCF building, had five exit doors through which residents could exit. Houses 2 and 3, secured MCC buildings, each had two exit doors through which residents could exit the building into secured outdoor areas. When the surveyor exited through these doors, no audible alert was heard. In an interview on 01/24/23, Staff 9 (Maintenance) confirmed there was no system that alerted staff when a resident exited any of the doors. On 01/25/23 Staff 9 was observed installing alarms in Building 3 and reported that alarms for the other two buildings had been ordered. 2. In a group interview on 01/25/23 an unsampled resident reported that his call light "works on and off". The resident's call light was tested and rang the first time but did not work the following four times. Staff 9 unplugged the cord and plugged it back in and the alarm worked on the following five tests. A repair log showed the call light had been repaired on 05/03/22. In an interview 01/25/23 Staff 9 stated the resident had not reported the repair as ineffective. On 01/26/23 Staff 1 (ED) reported she had called an electrician to repair the call light and that she would implement a quality control test log for the call light system. During a walk-through of the environment on 01/26/23, these finding were reviewed with Staff 1. She acknowledged the findings.

What actions will be taken to correct the rule violation? Door chimes installed on all exit doors, Call lights will be tested regularly. · How will the system be corrected so this violation will not happen again? Maintenance Director will test all door chimes to ensure that they are working monthly, each call light will be tested monthly as well and data kept on a log. · How often will the area needing correction be evaluated and who is assigned to evaluating the changes? All chimes and call lights will be checked monthly. · Who on your staff will be responsible to see that all the corrections are completed and monitored? The Maintenance Director and Executive Director

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231, C240, C420, C513 and C555.

Refer to POC for: C 231, C 240, C 420, C 513, and C 555

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 10, 11 and 12) completed all required pre-service orientation training prior to beginning their job responsibilities, and 3 of 3 long-term staff (#s 5, 13 and 14) completed a minimum of 16 hours of in-service training annually. Findings include, but are not limited to: Training records were reviewed on 01/25/23 with Staff 15 (Business Office Manager). The following deficiencies were identified: a. There was no documented evidence Staff 10 (CG), Staff 11 (CG), or Staff 12 (CG), hired 12/20/22, 12/05/22, and 11/14/22, respectively, completed approved infectious disease prevention training prior to beginning their job responsibilities. b. Staff 5 (MT), hired 02/28/19, Staff 13 (CG), hired 11/01/10, and Staff 14 (CG), hired 05/17/19, failed to complete 16 hours of annual in-service training during hire date intervals of 02/28/21-02/28/22, 11/01/21-11/01/22, and 05/17/21-05/17/22, respectively. The need to ensure newly-hired staff completed all required orientation training prior to beginning any job duties, and long-term direct care staff completed 16 hours of annual in-service training, which included six hours of dementia care training, was reviewed with Staff 15 on 01/25/23 and Staff 1 (ED) on 01/26/23. They acknowledged the findings.

What actions will be taken to correct the rule violation? Letters sent out to individuals needing training with the policy and annual training requirments per OAR's, and all employees training will be completed.   · How will the system be corrected so this violation will not happen again? New staff will not be permitted to work the floor until all pre-service trainings are complete. Training Completion Spreadsheet will be reviewed prior to scheduling any new staff. Training spreadsheet will be reviewed each month to ensure monthly trainings are being completed and a total of 16 hours of training will be done annually. · How often will the area needing correction be evaluated and who is responsible for the evaluation? RCC will review the staff training spreadsheet prior to scheduling any new staff. The BOM will enter dates of training completion into the spreadsheet and alert RCC of those staff members who have not completed the monthly training. · Who on your staff will be responsible to see that all corrections are completed/monitored? The RCC and Executive Director

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 C270.

Refer to POC for C 270

The findings of the re-licensure survey conducted 01/23/23 through 01/26/23 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 Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with the letter 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. 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

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 10/13/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the unannounced complaint investigation conducted 10/13/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. No deficiencies were identified in relation to the complaint.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the unannounced complaint investigation conducted 10/13/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. No deficiencies were identified in relation to the complaint.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 10/13/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day