Rosewood Memory Care

Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (# 5) and multiple non-sampled residents were treated with dignity and respect during meal service. Findings include, but are not limited to:

1. Observations were conducted during lunch on 06/30/25 and breakfast and lunch on 07/01/25. The following concerns were identified:

* Staff 11 (MA) approached and checked an unsampled resident’s blood sugar in the dining room; and
* Staff 13 (CG) was observed standing while assisting and feeding an unsampled resident who required cueing and physical feeding assistance. The resident was seated in a WC in the dining room, while Staff 13 remained standing while feeding the resident, rather than positioning at eye level or sitting beside the resident.

The need to ensure residents were treated with dignity and respect during meal service was discussed with Staff 1 (Regional Director of Operations), Staff 2 (Regional Nurse Consultant, RN), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) on 07/02/25 at 11:10 am. They acknowledged the findings.

2. Resident 5 moved into the facility in 05/2025 with diagnoses including senile degeneration of the brain and Alzheimer’s disease. Observations were made and interviews with staff and the resident were conducted, revealing the resident was bed-bound and dependent upon staff for all ADL needs, including full meal assistance.

Meal observations were made on 06/30/25 at 12:00 pm and 07/01/25 at 12:12 pm during lunch service. Staff 17 (CG) provided meal assistance to Resident 5 while resident was lying in bed with head elevated during both observations. Staff 17 remained standing while feeding the resident, rather than positioning at eye level or sitting beside the resident.

Ensuring residents were treated with respect and dignity while receiving meal assistance was discussed on 07/02/25 at 12:30 pm with Staff 1 (Regional Director of Operations), Staff 2 (Regional Nurse Consultant, RN), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN). They acknowledged the findings.

OAR 411-054-0027 (1) Resident Rights and Protection - General

(1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right:
(a) To be treated with dignity and respect.
(b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences.
(c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided.
(d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made.
(e) To receive information about the method for evaluating their service needs and assessing costs for the services provided.
(f) To exercise individual rights that do not infringe upon the rights or safety of others.
(g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse.
(h) To receive services in a manner that protects privacy and dignity.
(i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays).
(j) To have medical and other records kept confidential except as otherwise provided by law.
(k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone.
(l) To be free from physical restraints and inappropriate use of psychoactive medications.
(m) To manage personal financial affairs unless legally restricted.
(n) To have access to, and participate in, social activities.
(o) To be encouraged and assisted to exercise rights as a citizen.
(p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence.
(q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation.
(r) To be free of retaliation after they have exercised their rights provided by law or rule.
(s) To have a safe and homelike environment.
(t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion.
(u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to report injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office, if abuse or neglect could not be reasonably ruled out, for 1 of 1 sampled resident (#5) with incidents or injuries of unknown cause. Findings include, but are not limited to:

Resident 5 moved into the facility in 05/2025 with diagnoses including senile degeneration of the brain and Alzheimer's disease.

The resident’s progress notes, dated 05/13/25 through 06/30/25, and incident reports were reviewed, and the following was identified:

* An 05/26/25 incident report stated, “When changing resident this morning with cg mt [sic] noticed 2 skin tears to back of right hand… and another skin tear to left hand to knuckle of index finger.” The note continued, “Res [sic] not stating any pain and unsure how [he/she] got them. NOC shift informed morning shift that resident was showing aggression with bed changes.”

The above incident constituted an injury of unknown cause. The facility investigation ruled out abuse and neglect “due to no signs of distress.” An interview with Staff 1 (Regional Director of Operations), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) confirmed this was an injury of unknown cause, for which abuse could not be ruled out based upon the investigation and needed to be reported. The facility confirmed the self-report to the local SPD office on 07/01/25 at 12:00 pm.

The need to ensure injuries of unknown cause were reported to the local SPD office, if necessary, was discussed with Staff 1, Staff 2 (Regional Nurse Consultant, RN), Staff 3, and Staff 6 on 07/02/25 at 12:30 pm. The findings were acknowledged.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action

(Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 2 of 5 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 10/2024 with diagnoses including vascular dementia and COPD. Observations of the resident, interviews with staff and the resident, review of the service plan dated 04/08/25, interim service plans, and progress notes dated 01/22/25 through 06/30/25 were completed. The service plan was not reflective and did not provide direction for staff in the following areas:

* Use of tilt-in-space wheelchair;
* Ability to self-propel wheelchair in the community;
* Bilateral side rails; and
* Use of an air mattress.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Regional Director of Operations), Staff 2 (Regional Nurse Consultant, RN), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) on 07/02/25 at 12:45 pm. They acknowledged the findings.

2. Resident 2 moved into the memory care facility in 06/2025 with diagnoses including dementia and anxiety.

Observations of the resident, interviews with the resident and staff, and review of the service plan dated 06/19/25 were completed. The service plan was not reflective and did not provide clear directions to staff in the following areas:

* Toileting/incontinent care status;
* Receiving outside provider service including details on who to contact and under what circumstances;
* Use of side rails including any associated precautions; and
* Shower time preferences.

The need to ensure service plans were reflective of resident care needs and provided clear instructions for staff was reviewed with Staff 1 (Regional Director of Operations), Staff 2 (Regional Nurse Consultant, RN), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) on 07/02/25 at 11:10 am. They acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure infection prevention and control practices to provide a safe, sanitary, and comfortable environment during meal service. Findings include, but are not limited to:

1. During dining observations, conducted 06/30/25 through 07/02/25, Staff 13 (CG) was observed serving breakfast and lunch, and providing eating assistance to an unsampled resident in the dining room without wearing any barrier protection or apron.

Additionally, Staff 13 was observed performing various tasks between providing feeding assistance, including taking a resident to the bathroom, transferring, and escorting residents. However, during these direct care tasks and while assisting residents with feeding assistance, Staff 13 did not wear any protective barrier or apron.

2. Resident 5 moved into the facility in 05/2025 with diagnoses including senile degeneration of the brain and Alzheimer’s disease. Observations were made and interviews with staff and the resident were conducted, revealing that the resident was bed-bound and dependent upon staff for all ADL needs, including full meal assistance.

Meal observations were made on 06/30/25 at 12:00 pm and 07/01/25 at 12:12 pm during lunch service. Staff 17 (CG) provided meal assistance to Resident 5 without wearing any barrier protection or an apron during both observations.

3. During the survey, conducted 06/30/25 through 07/02/25, observations made during the dining service of breakfast and lunch on 06/30/25 and 07/01/25 showed Staff 15 (CG) provided eating assistance to unsampled residents in the dining room without wearing any barrier protection or an apron.

The need to ensure infection prevention and control practices were followed during meal service was discussed with Staff 1 (Regional Director of Operations), Staff 2 (Regional Nurse Consultant, RN), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) on 07/02/25 at 11:10 am. They acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control

(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

Based on interview, observation, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 2 and 4) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 10/2024 with diagnoses including vascular dementia and COPD. Resident 4's current physician's orders, MAR/TAR dated 06/01/25 through 06/30/25, and progress notes dated 01/22/25 through 06/30/25 were reviewed. The following was identified:

a. Resident 4 was prescribed a regular diet, mechanical soft texture. Lunch on 06/30/25 included lasagna, green beans, and a slice of garlic bread. It was noted that the resident’s lasagna was not cut up and the garlic bread was whole. On 07/01/25 for breakfast, the resident was served eggs and a whole biscuit with gravy, and lunch was chopped pork, mashed potatoes, chopped vegetables, and a whole dinner roll. However, Staff 7 (Food Service Director) confirmed Resident 4 was on a mechanical soft diet, and for that diet texture, lasagna should be cut up, green beans slightly overcooked to be softer, and garlic bread cut up. Additionally, Staff 7 indicated the biscuit and dinner roll needed to be cut up for a mechanical soft diet. During the observation, the resident did not eat the biscuit at breakfast and was able to take small bites of the dinner roll at lunch. The resident was able to cut up the food independently, and no difficulty chewing or swallowing was observed.

b. Resident 4 had an order for Ensure Plus twice a day, scheduled at 8:00 am and 5:00 pm, for nutritional support, and house health shakes 4oz after meals and at bedtime, scheduled at 9:00 am, 1:00 pm, 6:00 pm, and 8:00 pm for weight loss. Instructions included notifying the nurse if intake was less than 50%.

The MAR showed Ensure Plus and house health shakes were documented as administered. However, observation of the resident, staff interview, and the service plan showed the resident was not awake until about 9:00 am-10:00 am. Therefore, the 8:00 am and 9:00 am supplement were not administered. Additionally, the facility had no documented evidence to track the intake of the supplement in order to determine when to report to the nurse as prescribed for intake of less than 50%.

In an interview with Staff 10 (MA) on 07/02/25 at 10:55 am, s/he stated they would not administer the house health shake when the resident awakened but would administer Ensure plus instead. In addition, s/he confirmed they did not notify the nurse of intake less than 50%.
On 07/02/25, Staff 2 (Regional Nurse Consultant, RN) confirmed there was no documented evidence the facility was tracking the resident’s supplement intake.

The need to ensure all medication and treatment orders were carried out as prescribed was discussed with Staff 1 (Regional Director of Operations), Staff 2, Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) on 07/02/25 at 12:45 pm. They acknowledged the findings.

2. Resident 2 moved into the facility in 06/2025 with diagnoses including dementia and anxiety.

The resident’s 06/01/25 through 06/30/25 MAR and physician’s orders were reviewed, and staff interviews were conducted during the survey, revealing the following:

a. There was a physician order, dated 06/04/25, to serve mechanical soft diet. However, it was noted on 06/30/25 that lunch included garlic bread, green beans, and lasagna. On 07/01/25 breakfast included scrambled eggs and a biscuit with gravy, and lunch consisted of steamed vegetables, chopped meat, mashed potatoes, and a whole bread roll. On 06/30/25 and 07/01/25, staff interviews indicated that for a mechanical soft diet, items such as garlic bread, lasagna, biscuits, and whole bread should be cut up. Therefore, the physician’s order for a mechanical soft diet was not carried out as prescribed. During the meal, the resident did not show any signs or symptoms of coughing, choking, or aspiration. The resident ate slowly and was able to complete his/her meal independently.

b. A 06/15/25 physician order indicated to administer Fosamax 70 mg (to treat osteoporosis) weekly, at least 30 minutes before first food, beverage, or medication of the day. However, the MAR showed the medication was scheduled for 8:00 am, along with all other morning medications.

c. A 06/15/25 physician order indicated to administer vitamin B12 every other day. However, the MAR showed the medication was administered every day, not every other day as prescribed.

d. A 06/15/25 physician order indicated to apply Lidocaine patch daily for pain. However, the MAR showed the medication was not administered and was noted as “pending confirmation.”

e. A 06/15/25 physician order indicated to administer milk of magnesia 30 ml. However, the order was incomplete, as it did not include the route or the frequency for the medication to be administered.

f. A 06/15/25 physician prescribed staff should be notified if vital signs were out of range, provide treatment for minor skin laceration, apply house barrier cream, and offer the house health shake. However, these orders were not transcribed to the MAR for staff to carry out.

On 07/02/25 at 11:10 am, the findings were reviewed with Staff 1 (Regional Director of Operations), Staff 2 (Regional Nurse Consultant, RN), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) on 07/02/25 at 11:10 am. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications, including over-the-counter medications, that were ordered by a legally recognized prescriber and administered by the facility for 1 of 1 sampled resident (# 4) who received a nutritional supplement and whose MAR was reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 10/2024 with diagnoses including vascular dementia and COPD. Resident 4's current physician's orders, MAR/TAR dated 06/01/25 through 06/30/25, progress notes dated 01/22/25 through 06/30/25, and service plan dated 04/08/25 were reviewed. The following was identified:

* The resident had an order for Ensure Plus twice a day, scheduled at 8:00 am and 5:00 pm, for nutritional support and an order dated 06/06/25 for 4 oz house shakes after meals and at bedtime, scheduled at 9:00 am, 1:00 pm, 6:00 pm and 8:00 pm for weight loss. The MAR showed the Ensure Plus at 8:00 am and the house health shake at 09:00 am were documented as administered. However, observation of the resident, staff interview, and the service plan showed the resident was not awake until about 9:00 am – 10:00 am. Staff 10 (MA), on 07/02/25 at 10:55 am, reported they would document the house health shake as a refusal if the resident had not taken them. Review of MAR/TAR and progress notes revealed no documentation of refusals.

The need to ensure resident MARs were accurate was discussed with Staff 1 (Regional Director of Operations), Staff 2 (Regional Nurse Consultant, RN), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) on 07/02/25 at 12:45 pm. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potential restraining qualities was assessed in a timely manner prior to use and failed to provide instruction to caregivers on the use and precautions related to the us of the device, for 2 of 3 sampled residents (#s 2 and 4), who had supportive devices with restraining qualities. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 06/2025 with diagnoses including dementia and was observed to have bilateral half-length side rails on the bed.

Review of the resident's clinical record showed the assessment for the use of the side rails was completed by the RN during the survey on 06/30/25. Staff interview noted the resident had been using the side rails since moving into the facility.

Review of the resident’s service plan, dated 06/19/25, showed it did not include any instruction or precautions related to the use of the device.

The need to ensure any device with potential restraining qualities was assessed in a timely manner and staff were instructed on the use and precautions related to the use of the device was discussed with Staff 1 (Regional Director of Operations), Staff 2 (Regional Nurse Consultant, RN), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) on 07/02/25 at 11:10 am. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 10/2024 with diagnoses including vascular dementia and COPD.
During the survey, 6/30/25 through 07/02/25, the resident was observed utilizing a tilt-in-space wheelchair and bilateral half-length side rails on the bed.

Review of the resident's clinical record showed the lack of an assessment for the tilt-in-space wheelchair. Also, the assessment for the use of the side rails was completed by the RN during the survey, on 06/30/25. Staff interview noted the resident had been using the wheelchair and side rails since moving into the facility.

Review of the resident’s service plan, dated 04/08/25, showed it did not include any instructions or precautions related to the use of the devices.

The need to ensure any device with potential restraining qualities was assessed prior to use and provided clear instruction and precautions related to the use of the device was discussed with Staff 1 (Regional Director of Operations), Staff 2 (Regional Nurse Consultant, RN), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) on 07/02/25 at 12:45 pm. They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices

Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure direct care staff were scheduled and maintained staff according to their staffing plan to meet the 24-hour scheduled and unscheduled needs of the residents. Findings include, but are not limited to:

During the ABST review on 07/01/25, the following was identified:

* The memory care facility was home to 43 residents housed in two separate and distinct segregated areas: “Rose” (22 residents) and “Wood” (21 residents) areas;
* Eleven residents who required two staff members' (two-person?) assistance with transfers were housed within the two segregated areas;
* Multiple residents in both areas who required assistance in the dining room, including cueing or physical assistance with eating; and
* Five residents who needed support for behavioral symptoms.

There was one posted staffing plan for the facility, which indicated the following:

* Day shift: Four direct caregiving staff and two Medication Technicians;
* Evening shift: Four direct caregiving staff and two Medication Technicians; and
* Night shift: Two direct caregiving staff and one Medication Technician.

The ODHS ABST data reviewed on 07/01/25 revealed the following was needed for each distinct and segregated area:

* The “Rose” side, when calculated, indicated a need for four direct care staff on day and evening shift and two on night shift; and
* The “Wood” side, when calculated, indicated a need for four direct care staff on day shift and evening shift and two on night shift.

In an interview with Staff 1 (Regional Director of Operations) on 07/02/25 at 10:00 am, he confirmed these findings and that the facility was not staffed to their calculated staffing plan for each separate and distinct area.

A review of the facility’s scheduled staffing for the period of 06/22/25 through 06/28/25 revealed their staffing was not adequate to meet the evaluated care and service needs of residents based upon the ABST for “Rose” and “Wood” areas.

Staff 1 stated they were actively working to hire additional staff.

The need to ensure a sufficient number of direct care staff were scheduled to meet the 24-hour scheduled and unscheduled needs of residents and to meet the ABST staffing requirement for the segregated and distinct areas of the facility was reviewed with Staff 1, Staff 2 (Regional Nurse Consultant, RN), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) on 07/02/25 at 12:30 pm. They acknowledged the findings.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure all poisons, chemicals, and other toxic materials were stored in locked areas. Findings include, but are not limited to:

During the facility tour on 06/30/25, it was noted multiple chemicals, including buckets of sanitizing solution, bottles of a hand sanitizer, and barrier creams, were stored in unlocked cabinets in three of four kitchenette areas.

On 06/30/25 at 9:58 am, the area was toured with Staff 1 (Regional Director of Operations). The surveyor requested the removal of all chemical materials, which was completed at the time of request.

The need to ensure all poisonous chemicals were stored in a locked area was reviewed with Staff 1, Staff 2 (Regional Nurse Consultant, RN), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) on 07/02/25 at 11:10 am. They acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior

(3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:

Observation of the facility on 06/30/25 showed the following areas were in need of cleaning and/or repair:

* Room 212 door had visible gouges;
* Rooms 101, 102, 103, 104, 119, 205, 206, 209, 216, 223 and 224 doorframe had chips and gouges;
* The piano legs were chipped and gouged;
* Baseboard near Room 221 and the countertop were chipped and gouged;
* Unit A kitchenette, the lower cabinet shelves next to the refrigerator had missing laminate along the edges, exposing raw materials;
* Unit B kitchenette, the cabinets were chipped and gouged;
* Unit D kitchenette, the upper cabinet shelves had missing laminate at the edge with exposed raw materials.

On 07/01/25 at 10:30 am, the above areas were toured with Staff 16 (Regional Maintenance Director), who acknowledged the findings.

The need to maintain the interior of the facility, all equipment, and surfaces clean and in good repair was discussed with Staff 1 (Regional Director of Operations), Staff 2 (Regional Nurse Consultant, RN), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) on 07/02/25 at 11:10 am. They acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to locks on bathroom doors for shared bathrooms. Findings include, but are not limited to:

The facility consisted of a total of 48 rooms, each with a shared bathroom. During an interview and observation with Staff 16 (Regional Maintenance Director) on 07/01/25 at 10:30 am, it was noted that shared bathrooms had a locking mechanism on the outside/apartment side of the bathroom door; however, they lacked a locking mechanism on both sides of the inside of the bathroom door to ensure resident privacy.

The inability to lock the bathroom door from the inside for residents who shared the bathroom and used it for their toileting needs raised concerns regarding residents’ rights to privacy and dignity.

The need to ensure residents’ rights to privacy and dignity related to locks on bathroom doors was reviewed with Staff 1 (Regional Director of Operations), Staff 2 (Regional Nurse Consultant, RN), Staff 3 (Regional Nurse Consultant, LPN), and Staff 6 (RN) on 07/02/25 at 12:30 pm. They acknowledged the findings.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity

(1) Residential and non-residential HCB settings must have all of the following qualities:
(c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the individual the right to freedom from restraints for 2 of 2 sampled Residents (#s 2 and 4) who used supportive devices with restraining qualities.

Refer to C340.

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom

(1) Residential and non-residential HCB settings must have all of the following qualities:
(d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS
443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting.

This Rule is not met as evidenced by:

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: C200, C231, C360, C510, and C513.

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.

This Rule is not met as evidenced by:

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: C260, C295, C303, C310, and C340.

OAR 411-057-0160(2b) Compliance with Rules Health Care

(b) Health care services provided in accordance with the licensing rules of the facility.

This Rule is not met as evidenced by:

The findings of the relicensure survey conducted 4/26/21 through 4/28/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit of the re-licensure survey on 4/28/21, conducted 8/3/21, 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.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit of the re-licensure survey of 4/28/21, conducted 10/6/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and the OARs 411 Division 57 for Memory Care Communities.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day




The findings of the third re-visit to the re-licensure survey of 04/28/21, conducted on 12/7/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations. The facility was found to be in substantial compliance with the regulations.

Based on interview and record review, it was determined the facility failed to conduct an investigation of an injury of unknown cause to rule-out abuse and report the injury as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 1 of 2 sampled residents (#2) who experienced injuries of unknown cause. Findings include, but are not limited to:Resident 2 was admitted to the facility in 11/2016. During the acuity interview on 4/26/21, the resident was identified as high care needs and receiving Hospice services. Resident 2's clinical record identified the following deficiencies:* On 2/9/21, facility chart notes indicated the resident had bruising of unknown cause on right elbow the size of an orange, multiple bruises on right wrist and one on the left shin; * On 2/28/21, facility chart notes indicated the resident had a skin tear of unknown cause on the top of the right hand and the right forearm;* On 3/9/21, facility chart notes indicated the resident had a skin tear of unknown cause to the right chin; and * On 4/3/21, facility chart notes indicated the resident had an abrasion of unknown cause to the middle of the back.There was no documented evidence the facility immediately investigated the four injuries of unknown cause to rule out abuse. The facility did not report the injury to the local office as suspected abuse/neglect. The need to ensure injuries of unknown cause were investigated promptly and reported if necessary was discussed with Staff 1 (Administrator) on 4/28/21. Staff 1 acknowledged there was no documented evidence the facility had investigated the injuries to rule out abuse/neglect. The surveyor requested Staff 1 to self-report the incidents. Verification the facility had reported the four incidents as required, was received during the survey.
Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were promptly investigated to rule out abuse/neglect and were reported to the local SPD office when unable to reasonably conclude the incidents were not abuse and/or neglect for 2 of 2 sampled residents (#s 5 and 6). This is a repeat citation. Findings include but are not limited to: During the acuity interview on 8/3/21, Resident 5 and 6 were identified to have experienced bruising on their bodies.1. Resident 5's clinical record identified the following:* A 7/20/21 progress note indicated the resident was on alert charting for having two bruises on his/her left arm..."one by his/her wrist and the other one on his/her forearm. The size of the forearm is Orange and the one on his/her wrist quarter size..."On 8/3/21 at 9:30 am, Staff 4 (MT) stated the resident was new to the facility and was not sure of the cause of the bruises.There was no documented evidence the facility immediately investigated the above injury of unknown cause to rule out abuse. On 8/3/21 at 12:02 pm, Staff 3 (LPN) stated the investigation of the incident was not completed. Staff 3 provided the investigation of the incident prior to exit on 8/3/21.2. Resident 6's clinical record identified the following:* A 7/16/21 progress note indicated the resident was on alert charting for bruising on forehead..."Med tech believed resident got bruise from resident head on counter. Bruise is about as big as as grape." On 8/3/21 at 9:30 am, Staff 4 (MT) stated the resident was not sure of the cause of the bruise.There was no documented evidence the facility investigated the above injury of unknown cause to rule out abuse. On 8/3/21 at 2:05 pm, Staff 3 (LPN) stated she was not aware of the incident. On 8/3/21 at 2:20 pm, during the exit interview, Staff 12 (Executive Director) stated he was not aware of the incident. The need to ensure injuries of unknown cause were investigated promptly and reported if necessary was discussed with Staff 3 and Staff 12 during the survey. The staff acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 4/26/21 at 3:00 pm, the facility kitchen was observed to need repair in the following areas:* The tile floor near the threshold of the walk-in freezer was broken. This created an unsmooth, uncleanable surface, and a potential tripping hazard.The area that required repair was observed and discussed with Staff 1 (Administrator) and Staff 7 (Maintenance) on 4/27/21 and Staff 8 (Culinary Director) on 4/28/21. Staff 1 and Staff 7 confirmed there was no quote to repair the floor and they were not aware of the issue. The findings were acknowledged.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:On 8/3/21 at 10:03 am, the facility kitchen was observed to need repair in the following areas:* The tile floor near the threshold of the walk-in freezer was broken. This created an unsmooth, uncleanable surface, and a potential tripping hazard.The area that required repair was observed and discussed with Staff 8 (Culinary Director) and Staff 12 (Executive Director) on 8/3/21. Staff 8 confirmed the floor was not repaired and acknowledged the finding.

Based on interview and record review, it was determined the facility failed to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation. Findings include, but are not limited to:On 4/28/21, fire drill records from January 2021 to March 2021 were reviewed and lacked the following documentation:* Evidence the facility was providing fire and life safety instruction to staff on alternating months from fire drills;* Escape route used;* Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and* Number of occupants evacuated.On 4/28/21 the above areas were reviewed with Staff 1 (Administrator) and Staff 7 (Maintenance Director). No further information was received.
Based on interview and record review, it was determined the facility failed to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation. This is a repeat citation. Findings include, but are not limited to:During the entrance conference on 8/3/21, the surveyor requested Fire and life safety training and records. The following were identified:* No documentation of evidence the facility was providing fire and life safety instruction to staff on alternating months from fire drills;* No documentation of fire drills were conducted every other month;* No documentation of date and time of fire drill;* No documentation of location of simulated fire origin;* No documentation of escape route used;* No documentation of problems encountered and comments relating to residents who resisted or failed to participate in the drills; *No documentation of evacuation time-period needed;* No documentation of staff members on duty and participating; and* No documented evidence the number of occupants had been evacuated.On 8/3/21 the above areas were reviewed with Staff 12 (Executive Director). No further information was received.

Based on interview and record review, it was determined the facility failed to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation. This is a repeat citation. Findings include, but are not limited to:Fire drill records were requested and Staff 12 (ED) provided the fire drill evaluation and log completed on 09/14/21. The records lacked the following required information:* Location of simulated fire origin;* Escape route used;* Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and* Number of occupants evacuated.On 10/6/21, the above areas were reviewed with Staff 12 (ED). He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:Fire and life safety records dated 1/2021 through 3/2021 were reviewed and lacked the following required documentation:* Evidence alternative exit routes were used during fire drills; and* Staff interviewed knew the designated point of safety. The need to ensure all general fire and life safety requirements were followed was discussed with Staff 1 (Administrator) and Staff 7 (Maintenance Director) on 4/28/21. No further information was received.
Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. This is a repeat citation. Findings include, but are not limited to:During the entrance conference on 8/3/21, the surveyor requested Fire and life safety training and records. The following were identified:* No documentation of alternate escape routes used during fire drills; and* No documentation of annual training for residents that included general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting place.The need to ensure all general fire and life safety requirements were followed was discussed with Staff 12 (Executive Director) on 8/3/21. No further information was received.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. This is a repeat citation. Findings include, but are not limited to:Fire drill records were requested and Staff 12 (ED) provided the fire drill evaluation and log completed on 09/14/21. The records lacked the following required information:* Evidence of alternate escape routes used during fire drills; and* Staff interviewed know the designated point of safety.The need to ensure all general fire and life safety requirements were followed was discussed with Staff 12 (ED) on 10/6/21. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure its re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C231, C240, C420, C422 and C540.
Based on observation, interview and record review, it was determined the facility failed to ensure its re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 420, C 422 and C 540.

Based on observation and interview, it was determined the facility failed to ensure courtyard pathway edges did not contain drop offs to prevent tripping hazards for residents. Findings include, but are not limited to:Observations of the exterior of the facility on 4/26/21 and 4/27/21 showed drop offs at the pathway edges in excess of two inches in multiple areas, creating a trip hazard.The need to ensure pathways in the resident courtyard did not have potential tripping hazards was shown to and discussed with Staff 1 (Executive Director) and Staff 7 (Environmental Services Director) on 4/27/21. The staff acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:During a tour of the facility on 4/26/21, wall heaters were identified in the bedrooms of all resident apartments.The heaters were turned on by the surveyor, tested with a thermometer, and found to have surface temperatures ranging from 185 to 195 degrees Fahrenheit.Staff 1 (Executive Director) and Staff 7 (Environmental Services Director) were informed, and observed the high temperature readings with the surveyor. Staff 1 and Staff 7 acknowledged the need to ensure wall heater covers did not exceed 120 degrees Fahrenheit, and turned off all wall heaters.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. This is a repeat citation. Findings include, but are not limited to:During a tour of the facility on 8/3/21, wall heaters were identified in the bedrooms of all resident apartments.The heaters were turned on by Staff 10 (Environmental Services), tested with a surveyor's thermometer, and found to have surface temperatures ranging from 134 to 161 degrees Fahrenheit.Staff 12 (Executive Director) and Staff 10 were informed, and observed the high temperature readings with the surveyor. Staff 10 and Staff 12 acknowledged the need to ensure wall heater covers did not exceed 120 degrees Fahrenheit, and turned off all wall heaters.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. This is a repeat citation. Findings include, but are not limited to:During a tour of the facility on 10/06/21, wall heaters were identified in the bedrooms of all resident apartments. The wall heaters had metal plates installed over a portion of the wall heater grates.The heaters were tested with a surveyor's thermometer and found to have surface temperatures that exceeded 135 degrees Fahrenheit on some areas of the metal plate.Staff 12 (ED) observed the temperature readings with the surveyor. Staff 12 acknowledged the need to ensure wall heater covers did not exceed 120 degrees Fahrenheit.

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 231, C 240, C 420, C 422, C 510 and C 540.

Based on observation, interview 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 C231, C240, C420, C422 and C540.


Based on observation, interview 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 C 420, C 422 and C 540.