Prestige Senior Living Orchard Heights Memory Care

Based on interview and record review, it was determined the facility failed to ensure incidents, and/or injuries of unknown cause were promptly investigated to rule out abuse, and reported to the local SPD office when required, for 2 of 4 sampled residents (#s 1 and 3). Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 10/2024 with diagnoses including dementia.

Resident 3 was observed to be independent with transfers and ambulation without an assistive device, often carrying or following his/her dog throughout the common areas of the facility.

Interviews with staff, observations of the resident, and review of the resident's 03/23/25 through 06/23/25 service plans, temporary service plans, progress notes, and accident/incident reports were completed and identified the following:

* On 04/23/25 progress notes indicated two bruises located by the resident’s left elbow were observed;

*On 06/03/25 the progress notes indicated the resident had a fall with an abrasion to the right elbow and bruising to the left elbow.

On 06/24/25 Staff 2 (Memory Care Director) reported there were no investigations completed for the incidents to reasonably rule out abuse, and the incidents were not reported to the local SPD.

The need to immediately report incidents with injury, and injuries of unknown cause to the local SPD office unless an immediate investigation reasonably concluded that the incident and/or injury was not the result of abuse was discussed with Staff 1 (ED), Staff 2, and Staff 3 (LPN) on 06/24/25. They acknowledged the findings.

The facility was instructed to report the injury of unknown cause to the local SPD office on 06/24/25, and confirmation of report sent was received from the facility by 3:30 pm on 06/24/25.

2. Resident 1 was admitted to the facility in 04/2025 with diagnoses including Alzheimer’s disease.

Observations of the resident, interviews with staff, and review of the resident's 06/11/25 service plan, 04/14/25 through 06/23/25 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was able to communicate needs to staff, complete some ADL care on his/her own, walked with a walker and had a vision impairment. The resident was not consistently compliant with requesting assistance from staff.

Review of the resident's records showed the following:

* A progress note dated 05/02/25 at 2:49 am, indicated the resident experienced a non-injury fall.

An investigation was not completed at the time of the incident.

* A progress note dated 05/02/25 at 8:32 pm, indicated the resident tripped in his/her apartment and fell. The resident sustained a skin tear to the elbow and an abrasion to the back and knee.

An investigation was not completed at the time of the incident.

* A hospice visit note dated 06/09/25 indicated the resident had a small skin tear to the left arm.

There was no other information regarding the skin tear or the cause. The resident did not offer any information on what might have happened. No investigation was completed regarding the injury of unknown cause.

The facility was asked to report the injury of unknown cause to the local SPD office. A confirmation of the report was provided to the surveyor.

The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect was discussed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (LPN) on 06/24/25. The staff acknowledged the findings.

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 and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that was based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to:

During the survey, 06/23/25 through 06/24/25, observations of the Memory Care unit showed minimal group activities. The television was on throughout the day. A small group of residents participated in a music activity one afternoon, and one to two individual residents were observed to paint or color after staff set up. Additional residents were observed sleeping in their chairs, in their rooms or wandering the common area, dining room and halls, throughout the rest of the day. Care staff were not observed to initiate any additional large or small group activities or offer the residents other things to do.

Staff 10 and Staff 12 (CGs) indicated they did not have a specific activity director for the Memory Care unit. Staff 12 indicated there were supplies in the cupboard and they tried to do the things on the activity calendar but were not always successful. The staff indicated the television, or music was usually kept on, some residents were happy watching TV. Staff 12 indicated they recently did some pot painting and planting with several residents.

The need to ensure a daily activity program was provided for residents to address their mental, physical and psychosocial needs was reviewed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (LPN) on 06/24/25. The staff acknowledged the findings.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities

(c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs;

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition had resident-specific instructions or interventions developed and communicated to staff and weekly progress documented until resolution for 2 of 4 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 04/2025 with diagnoses including Alzheimer’s disease.

Observations of the resident, interviews with staff, and review of the resident's 06/11/25 service plan, 04/14/25 through 06/23/25 temporary service plans, progress notes, physician communications, and incident investigations were completed.

Multiple daily observations were made of the resident between 06/23/25 and 06/24/25. The resident was observed while in his/her bedroom as well as common areas. The resident spent the majority of his/her time in bed.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas:

* Behaviors including anxiety and restlessness;
* Skin tear, bruises and skin injuries;
* Medication changes;
* Nausea and vomiting;
* Non-injury fall; and
* Low blood pressure and dizziness.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution, interventions were reevaluated for effectiveness and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (LPN) on 06/24/25. The staff acknowledged the findings.

2. Resident 2 was admitted to the facility in 01/2025 with diagnoses including senile dementia.

Observations of the resident, interviews with staff, and review of the resident's 05/13/25 service plan, 03/23/25 through 06/23/25 temporary service plans, progress notes, physician communications, and incident investigations were completed.

Multiple daily observations were made of the resident between 06/23/25 and 06/24/25. The resident was observed while in his/her bedroom as well as common areas. The resident spent a majority of his/her day in the common areas and walking the halls. The resident had a four wheeled walker that s/he intermittently used while walking the unit.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas:

* Thigh rash, itchy bumps and skin injuries;
* Behaviors including restlessness and wandering;
* Skin tear, bruises and skin injuries;
* Medication changes;
* Emergency room visit and hospital return;
* Shortness of breath and chest pains;
* New roommate;
* Compression stockings on extended period; and
* Nausea, vomiting and diarrhea;

The need to ensure short-term changes of condition had documentation of weekly progress until resolution, interventions were reevaluated for effectiveness and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (LPN) on 06/24/25. The staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure staff utilized proper infection control while serving in the dining room. Findings include, but are not limited to:

Observations of the dining room during lunch and dinner meal on 06/23/25 and breakfast meal on 06/24/25 showed the following:

* One care staff served the food onto plates for delivery. One to two additional staff served the plates and fluids to residents in the dining room. The staff were not wearing aprons or other clothing covers when serving food on 06/23/25. Staff on 06/24/25 had aprons in place but were wearing the aprons out of the dining room and into resident rooms and/or common areas.
* Staff were observed with gloves on. Multiple staff were touching other surfaces including doors, wheelchair handles, and dirty dishes without a change of gloves.
* Staff were exiting and entering the dining room without consistently changing gloves or washing hands.
* Staff were reminded to only use aprons in the dining room/kitchen area and remove prior to leaving the area. One staff was asked to remove the apron she had worn into a resident room and put on a fresh apron. Staff were also asked to change gloves between clean and dirty tasks.

The need to ensure staff consistently used proper infection control, hand hygiene and glove use was discussed with Staff 1 (ED) and Staff 2 (Memory Care Director) on 06/24/25. The staff 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 and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 9, 13, and 16) demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed, with Staff 1 (ED) on 06/24/25 and the following was identified:

There was no documented evidence that Staff 9 (CG), Staff 13 (CG), and Staff 16 (CG), hired 02/20/25, 03/05/25, and 03/20/25, respectively, had demonstrated competency in one or more of the following areas:

* First aid; and
* Abdominal thrust.

The need to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire was discussed with Staff 1 on 06/24/25. She acknowledged the findings

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

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code on alternate months. Findings include, but are not limited to:

Fire and life safety records, reviewed between 01/2025 and 06/2025, showed:

* One fire drill was documented as completed in the last six months for the Memory Care unit;
* Fire drills were not conducted on alternating months with fire life safety training; and
* Drills were not conducted on alternating shifts to include all three shifts.

Fire drill documentation was missing the following components:

* Escape route used;
* Problems encountered;
* Evacuation time period needed;
* Staff who participated in the drill;
* Number of occupants evacuated; and
* Evidence alternate routes were used.

The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from life safety training, was discussed with Staff 1 (ED) on 06/23/25 and 06/24/25. She acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to:

Fire and life safety records were reviewed and discussed with Staff 1 (ED) on 06/24/25. There was no documentation that residents were provided fire training within 24 hours of admission and again at least annually, related to general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire.

In an interview on 06/24/25, Staff 1 indicated she discovered the facility had not been fully documenting specific training on admission or annually with residents. Staff 1 acknowledged the need to provide the residents fire and life safety training.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents

(5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

This Rule is not met as evidenced by:

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

Observations of the facility on 06/23/25 and 06/24/25 showed the following areas in need of cleaning or repair:

* Multiple carpet stains were noted in the tv room. The stains varied in size and included black and red stains;
* Multiple scuffs, gouges and deep scratches were noted to the laminate flooring in the dining room, tv room and sitting area. Scratches were several inches in length at the minimum;
* Ceiling lights in the dining room had numerous dead insects and debris gathered in the lights;
* Spills, scrapes, splatters and debris were noted in the drawers, cupboards, walls and windowsills in the dining room. The curtains in the dining room had multiple spills and splatters with black/brown/white discolorations;
* Furniture in the tv room and sitting area had rips, stains, spills and/or debris on seats, arms and sides;
* Multiple dining room chairs had debris in seat crevices, spills and/or stains along fabric seat backs and on the sides of the furniture. The chairs had significant scrapes and gouges along chair legs and arms;
* Room 11 had missing flooring at the doorway;
* Shower room had scrapes, spills and dings to walls, missing grout or black caulking around the shower and flooring that was pulling apart at seems which created a gap for debris;
* The common area bathroom had cracks in the edges of the floor and a large section of flooring along the baseboard pulling away from the wall; and
* Multiple wall corners throughout the facility had chunks of missing plaster.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) on 06/23/25. She 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 a manually operated emergency call system was located in each toilet facility used by residents and visitors. Findings include, but are not limited to:

Observations on 06/23/25 and 06/24/25 showed the common bathroom was unlocked and accessible by residents. Observations of the interior of the restroom on 06/23/25 showed there was no manually operated call system for residents or visitors to obtain help. Staff 1 (ED) confirmed there was no call system in the restroom.

The facility had multiple ambulatory residents who moved around the halls and common areas. No residents were observed to use the common bathroom.

In interview on 06/23/25 Staff 5 and Staff 10 (CGs) indicated the bathroom was usually unlocked. The staff did not take residents into the bathroom but there were some residents who would take themselves into the bathroom to use it.

The need to ensure all toilet facilities used by residents and visitors was equipped with a manually operated call system was discussed with Staff 1 on 06/24/25. She acknowledged the findings.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable

(11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit.

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 no locks on bathroom doors for residents who had shared bathrooms. Findings include, but are not limited to:

Observations on 06/23/25 of shared bathrooms revealed there was no locking mechanisms on shared bathroom doors to ensure privacy.

On 06/23/25, the observations and the need to ensure shared bathroom doors had locks were reviewed with Staff 1 (ED) and Staff 6 (Memory Care Director). The staff acknowledged the findings.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(d) Each individual has privacy in his or her own unit.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their individual units. Findings include, but are not limited to:

Review of records for Residents 1, 2, 3, and 4 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms.

During an interview on 06/24/25 Staff 1 (ED) reported there was one resident on the unit who had requested and been provided a key to his/her room.

The need to ensure all residents were provided keys to their individual units was discussed with Staff 1 on 06/24/25. She acknowledged the findings.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

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. This is a repeat citation. Findings include, but are not limited to:

Refer to C231, C242, C295, C372, C420, C422, C513 and C555.

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 interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 9, 11, and 13) completed all orientation, pre-service and dementia training topics prior to performing any job duties, 3 of 3 staff (#s 9, 13, and 16) demonstrated competency in all required areas within 30 days of hire, and 2 of 2 long term staff (#s 7 and 15) completed the required number of annual in-service training hours, and Home and Community Based Care (HCBS) training. Findings include, but are not limited to:

A review of staff training records with Staff 1 (ED) on 06/24/25 identified the following:

* There was no documented evidence that Staff 9 (CG), Staff 11 (CG), and Staff 13 (CG), hired 02/20/25, 05/26/25, and 03/05/25, respectfully, had completed all orientation, pre-service training topics, and dementia training prior to performing any job duties to include one or more of the following:

- Abuse reporting requirements;
- Fire safety and emergency procedures;
- Infectious disease prevention;
- Approved LGBTQIA2S+ course;
- Environmental factors that are important to a resident’s well-being;
- Family support and the role the family may have in the care of the resident; and
- Use of supportive devices with restraining qualities in Memory Care communities.

* There was no documented evidence that Staff 9 (CG), Staff 13 (CG), and Staff 16 (CG), hired 02/20/25, 03/05/25, and 03/20/25, respectfully, had demonstrated competency in all required areas within 30 days of hire to include one or more of the following:

- Role of the service plan in providing individualized care;
- Providing assist with ADL cares;
- Changes associated with normal aging;
- Identification, documentation and reporting of changes of condition;
- Conditions that require assessment, treatment, observation and reporting; and
- General food safety, serving, and sanitation.

* There was no documented evidence that Staff 15 (CG), hired 06/13/23, respectively, had completed at least 10 hours of annual in-service training related to the provision of care in CBC within their anniversary date of hire (06/13/24 through 06/13/25).

* There was no documented evidence that Staff 15 (CG), hired 06/13/23, had completed a minimum of 6 hours of annual in-service training related to dementia care within their anniversary date of hire (06/13/24 through 06/13/25).

* There was no documented evidence that Staff 7 (MT) and Staff 15 (CG), hired 06/06/19, and 06/13/23, respectfully, had completed the required HCBS training.

The need to ensure staff training requirements were completed in the specified time frames was discussed with Staff 1 on 06/24/25. She acknowledged the findings.

OAR 411-057-0155(1-6) Staff Training Requirements

(1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

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 C270.

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:

Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, effectively sanitized dishes and stored food in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

1. Observation of the ALF kitchen and Memory Care Kitchenette on 05/02/25 at 10:45 am through 2:15 pm revealed the following deficiencies:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following:

* Door thresholds on kitchen entry and exit doorways
* Floor corners in the threshold of entry and exit doors
* Industrial can opener
* Industrial mixer
* Walk in cooler drain on outside of walk in
* Hand washing sink area with splatter
* Faucet and area around handwashing sink
* Ceiling vent above ice machine
* Kitchenette reach in refrigerator and freezer
* Kitchenette microwave
* Kitchenette oven
* Kitchenette drawers/cupboards
* Kitchenette wall behind trash can

b. The following was observed needing to be repaired.

* Caulking around hand washing sink was cracked/missing or had black substance build up.
* Dish machine in Memory Care Unit was not registering any concentration of sanitizing agent.

c. Dining room silverware was observed to be pre-set upon entry to facility at 10:45 am, Lunch was served at 12:00 pm. Kitchen staff stated lunch tables were set immediately following breakfast meal service. Food contact surfaces of utensils were not wrapped/covered to protect from potential contamination.

d. Staff 2 (Cook/Person In Charge designee) was observed preparing and serving food without appropriate facial hair restraints.

e. No surface sanitizing buckets were observed upon entry and throughout kitchen inspection to ensure effective sanitation during meal prep and service. Staff 2 was interviewed and acknowledged no buckets were made.

f. Ice machine was observed to have drain pipe directly inside of kitchen drain. No air gap was visible to ensure any drain back up would not potentially contaminate the ice machine. A long tube was observed sitting in the drain under the stainless steal prep table where can opener was located. Staff were asked what the tube was for and they indicated it was a water line for a juice machine connection. Staff indicated it was not in use and had not been in use. However, they confirmed it was an active water line. Surveyor instructed the line needed to be up and out of the drain and create at least an inch air gap to prevent potential contamination.

g. Staff 2 was designated person in charge and was not able to effectively demonstrate knowledge in potential illnesses that would be excludable and reportable as per food code.

h. Facility did not have or could not locate a copy of the Oregon Food Sanitation rules as required.

i. Dish machine in Memory Care Unit was a low temperature machine requiring chemical sanitation. There were no test strips in memory care kitchenette for staff to validate effective sanitation of dishes. Staff verified that all plates, cups, utensils were washed/sanitized in the dish machine for resident meal service. Staff available at meal time did not know the sanitizing chemical used nor the effective PPM (parts per million) that would be required. Staff verified that they did not check the machine for effective sanitation. At 1:45 pm Staff 3 (Maintenance Director) indicated an outside vendor comes in to check sanitation levels for the dish machines. Documentation indicated the memory care dishwasher had not been monitored by vendor since 11/6/24. Staff 3 also indicated he did not check the dish machine sanitation levels.

j. Multiple food items were found in the memory care unit reach in refrigerator without dates opened or prepared. A bag of cereal was observed in a cupboard open to potential contamination.

k. At 12:06 pm, Two plates of breakfast type foods were found sitting on top of the stove in memory care unit. Staff indicated those plates were for residents who did not come to breakfast and who wanted something to eat later. Staff indicated this was a common practice to set aside plates of food and to discard it once lunch was served. Staff acknowledged it was not stored in the refrigerator and was out since 8 am. Staff 2 and Staff 1 were notified of this practice and both acknowledged those food items should have been placed in the refrigerator to be warmed/reheated not left on the counter.

l. Memory care staff member was observed to not demonstrate effective knowledge on use of thermometer for checking temperatures prior to food service. Staff was not aware that the thermometer probe needed to be inserted into the food product until instructed by the surveyor. Staff was then observed to not sanitize the thermometer before temping the food nor in between food products potentially contaminating the foods.

m. Memory care staff did not have on aprons/effective barriers to protect from potential contamination from care duties during meal service.

n. Memory care staff were observed to potentially contaminate gloves during meal service by reaching in drawers/cupboards and not change gloves then touch ready to eat foods with those potentially contaminated gloves.

o. Kitchenette area did not have enough effective service utensils for all food types. Staff was observed to attempt to serve out chowder soup using a slotted spatula as no more service ladles/spoons were available.

p. A staff member’s lunch box was observed sitting on top of the memory care kitchenette toaster potentially contaminating the surface where ready to eat foods are prepared. Multiple staff drinks were observed that were not of approved style types that did not have lids and/or straws as required per rule.

At approximately 1:30 pm surveyor reviewed above with staff 2 who acknowledged areas. At 1:45pm surveyor reviewed identified areas with Staff 1 (Business Office Manager) who acknowledged the concerns.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

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

This Rule is not met as evidenced by:

Based on 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 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:

The findings of the kitchen inspection, conducted 02/15/24, 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 survey of 02/15/24, conducted 05/02/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, record review, and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the main facility kitchen, food storage areas, food preparation, and food service on 02/15/24 revealed:a) splatters, spills, drips, dust and debris noted on: - Can opener casing; - Industrial can opener; - Interiors of drawers; - Walk-in freezer floors; - Service/utility carts and wheels; - Smoke detector near/above a dishwashing area; - Interior of oven; - Interior and exterior of microwave; - Food contact and non food contact surfaces of the industrial slicer; - Food delivery cart; - Screen door with dust build up; and - Shelf under microwave. b. The following areas were in need of repair: - Caulking near hand washing was missing, cracked or found with black matter; - Walls and caulking around dish machine area with build up of black debris; - Industrial slicer not working; - Left oven not operational and; - Screen door to outside not latching/handle broken off.* Kitchen staff observed to handle ready to eat foods with potentially contaminated gloves. Staff wearing same gloves that handled fry pan and spatula cooking chicken breast, open refrigerator door, touching container of ranch dressing and sour cream and then handling flour tortillas, shredded lettuce and shredded cheese.2. Memory care unit (Expressions) kitchenette was observed at 11:40 and revealed:a) splatters, spills, drips, dust and food/debris noted on: - Exterior of food delivery cart; - Clean dish storage cart; - Interior of reach in refrigerator and freezer; - Interior and exterior of microwave; - Exterior of oven; - Behind sink; - Cabinet under sink; - Wall behind trash can; and - Kitchenette flooring.b) Multiple cold food items were found without use by or open dates. A carton of unpasteurized eggs found multiple days past the used by date. Containers of food items for residents without dates or resident identifier information.c) Previously frozen cartons of nutritious shake beverages found thawed without a use by date for their thawed state.d) Care staff were not wearing aprons or other protective layer during meals service to prevent potential spread of infectious agents on clothing from care giving tasks. One staff member was observed in the kitchenette area without their hair restrained.e) Multiple dry food items were not dated or securely closed after opening to ensure they were protected from contamination.f) Staff did not properly sanitize thermometer probes between checking temperatures of multiple food items potentially contaminating the food products.g) Recyclable items were not stored in appropriate receptacles as required.h) A serving utensil was found stored in the ice bin in the reach in freezer. A spoon was found in the container of brown sugar.At approximately 2:00 pm, the areas in need of cleaning, repair and attention were reviewed with Staff 1 (Executive Director). S/he acknowledged the findings.

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

The finding of the kitchen inspection, conducted on 12/07/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 12/7/22, conducted 2/22/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, record review and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the main facility kitchen, food storage areas, food preparation, and food service on 12/7/22 revealed:a) splatters, spills, drips, dust and debris noted on: - Juice machine; - Can opener casing; - Industrial mixer, safety cage and stand; - Interiors of drawers; - Open stainless steel shelving throughout kitchen; - Underneath shelving and equipment; - Legs of equipment, prep tables, shelves; - Walk-in refrigerator and freezer floors; - All food storage racks/shelves in dry good storage, walk-in refrigerator and freezer; - Floors throughout kitchen in corners and underneath equipment; - Service/utility carts and wheels; - Dish machine; - Walls behind, near and under the dish machine; - Can storage rack in dry goods area; - Walls throughout kitchen; - Smoke detector near/above a prep area; - Ceiling with dust, staining, splatters; - Window seal near beverage prep area; - Top of steam/tray line service; - Exterior of the range, range top, grill flat top and grease trap were found with grease and food debris build up; - Floor mats with debris build up; - Light switch with build up making it not a smooth cleanable surface and or with visible food debris; - Sides and top of commercial toaster; - Walls and caulking underneath knife storage; - Interior and exterior of microwave; - Food contact and non food surfaces of industrial slicer; - Drawers and cabinet under sink of the beverage station in dining room; and - Drains throughout the kitchen area.b) The following areas were in need of repair: - Caulking near hand washing sink was missing, cracked or found with black matter; - 3-4 inch hole on left wall near the ceiling as you entered the kitchen; - Hand washing sink near exit to dining room with build up around faucet - Large ice build up in freezer; - Ice build up in pipe in walk-in refrigerator; - Chips, nicks peeling paint on wall next to eye station; - Cabinet drawers of beverage station in dining room damaged/warped; - Caulking missing on beverage station in dining room; and - Entry and exit doors to kitchen with worn/missing/peeling paint.* White cutting boards found with deep scoring and staining. * Clean dishes were being stored on racks/shelves that were dirty and dusty.* Kitchen staff observed handling clean dishes after handling dirty dishes without washing or sanitizing hands.*Kitchen did not have a small diameter probe thermometer for checking temperature of thin foods.Staff 2 (Dining Services Director) and the Surveyor toured the kitchen. Staff 2 acknowledged the above findings.At approximately 12:30 pm, the memory care dining and meal service area was toured. Residents had just been served meal and food items (baked chicken, potatoes and vegetables) were observed in the steam table. Carestaff were interviewed regarding meal service procedures. Both staff indicated that food items were brought over from the main kitchen and placed in the steam table and temperatures checked prior to service. Food items were dished from pans onto plates and served to residents. The Carestaff stated the chicken that was served temperature was at about 110 degrees Fahrenheit. When asked what is the process if temperatures are not high enough to serve, both staff indicated they would go back to kitchen have the chicken reheated to the correct temperature. The Surveyor asked what temperatures the chicken should be at before service, and the response was 110-115 degrees Fahrenheit. Staff were not aware that food needed to be served at 135 degrees or higher. Staff indicated food temperatures were typically around 110-115. All residents had already been served and were eating or had finished their lunch. The surveyor was in kitchen when items were cooked to appropriate temperature and put in heated transport cart for delivery to memory care section.At 1:00 pm, Staff 2 was interviewed and stated that the "hot box" was heated to approximately 150 degrees Fahrenheit. Staff 2 acknowledged that memory care staff should be serving hot food items at 135 or higher. Upon investigation it was determined by facility staff that the steam table at memory care center must have been accidentally turned down and was not "hot enough" that meal. Staff 2 verified that the memory care staff would be re-educated on appropriate holding/serving temperatures.At approximately 1:15 pm, the areas in need of cleaning, and repair were reviewed with Staff 1 (Administrator). She acknowledged the findings and assured the Surveyor that the hot holding equipment for memory care would be looked at, fixed and/or adjusted as soon as possible to ensure food would be held/served at appropriate temperatures.

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Refer to C240.

The findings of the relicensure survey conducted 06/27/22 through 06/29/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 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 first revisit to the relicensure survey of 06/29/22, conducted 09/21/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.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 to the re-licensure survey of 06/29/22, conducted 12/20/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.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 revisit to the re-licensure survey of 06/29/22, conducted 04/10/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Home and Community Based Services Regulations OARs 411 Division 004 and Division 57 for Memory Care Communities.

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental, and psychosocial needs. Findings include, but are not limited to:At entrance on 6/27/22, the survey team was informed there was no activity director for the memory care unit, and that caregivers were responsible for providing activities in addition to their regular duties.During the survey, many residents in the MCC were observed in their rooms for most of the day. Approximately eight residents were observed sitting in the TV room or walking around the units at some point during the daytime. Review of the MCC activity calendar indicated four scheduled activities for 06/27/22:* 10:00 am "Balloon bat",* 01:00 pm "Bingo with Rolando",* 02:00 pm "walk about in the community" and* 03:00 pm "color crew".Observations by the survey team throughout the day revealed none of the scheduled activities occurred.On 6/28/22 the survey team did observe a staff person attempt to initiate kicking a ball between a group of seated residents, however, none of the 06/28/22 scheduled activities or any other unscheduled activities occurred.The need to ensure the facility provided a daily program of social and recreational activities for residents was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were completed prior to the resident being admitted to the facility for of 1 of 1 sampled resident (#5) who recently moved in. Findings include, but are not limited to:Resident 1 was admitted to the facility on 06/07/22. The resident's move-in evaluation was dated 06/07/22. The following elements were not addressed in the move-in evaluation:* Personality, including how the person copes with change or challenging situations; and* Environmental factors which impact the resident's behavior, including, but not limited to, noise, lighting, and room temperature.The need to ensure resident evaluations addressed all of the required components was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 03/22 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the service plan, dated 04/21/22 and progress notes showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Home health services and daily exercise program, * Diabetic dietary restrictions, and* Walking assistance and safety.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the service plan, dated 05/31/22 and progress notes showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Mobility and assistance needed in wheelchair;* Foam cushion in wheelchair;* Finger foods;* Fall matt next to bed;* Behavior pattern of wandering/shopping;* Lower extremity edema with interventions; and* Recurrent lower extremity wounds.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in Training) on 06/29/22. They acknowledged the findings.
3. Resident 5 was admitted to the facility in 04/2018 with diagnoses including dementia.Interviews with staff and review of the service plan revealed the service plan was not reflective in the following areas: * Assistance needed for eating;* Change in the amount and type of food eaten; and* Open area on coccyx. The need to ensure the resident's service plan was reflective of the care and services to be provided by staff was discussed with Staff 3 (Regional RN) and Staff 15 (LPN) on 09/21/22. Staff acknowledged the findings.
2. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia.a. Resident 2's most recent service plan dated 08/22/22 included the interventions"now has a fall alarm that stay attached to shirt and where [s/he] is sitting or laying", "hospice has provided a fall alarm tab for [Resident 2]. This is attached to [him/her] at all times", and "now has a fall alarm placed where [s/he] is sitting".Observations on 09/21/22 showed Resident 2 seated in the TV room, the dining room, and the activity room, without the fall alarm.Interviews with staff revealed they only used the tab alarm at night when Resident 2 was sleeping, and observations on 09/21/22 showed the fall alarm on the bed.b. Resident 2's most recent service plan dated 08/22/22 included the intervention "Hospice is asking that Med Techs are to offer Tylenol first due to possibly pain before giving the PRN lorazepam". In interview on 09/21/22, Staff 3 (Regional RN) acknowledged the information on the service plan was not being followed.On 09/21/22, the need to ensure service plans were reflective of residents current needs and provided clear directions to staff was discussed with Staff 3 and Staff 4 (ED). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and provided clear direction to caregiving staff regarding delivery of services for 3 of 3 sampled residents (#s 2, 5 and 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 02/2020 with diagnoses including dementia.Interviews with multiple staff members, on 09/21/22, identified Resident 6 was having exit seeking behaviors. Resident 6's service plan, dated 08/11/22, was not reflective of the resident's current status and failed to provide clear instructions to staff related to exit seeking behaviors. On 09/21/22, the need to ensure service plans were reflective of residents current needs and provided clear directions to staff was discussed with Staff 3 (Regional RN) and Staff 4 (ED). They acknowledged the findings.


2. Resident 6 was admitted to the facility in 02/2020 with diagnoses including dementia and was recently admitted to hospice.Observations of the resident and interviews with staff were conducted during the survey. The current service plan dated 10/26/22, the "Bedside Individual Service Plan" dated 12/20/22, and progress notes from 11/05/22 through 12/20/22 were reviewed.The service plan was not reflective and did not provide clear instructions in the following areas:* One to two person transfer assist;* Ambulation assist;* Meal assist;* Hospice services being provided;* Bowel incontinence;* Medication refusals; and* Fall history, including interventions. The need to ensure service plans were reflective and provided clear instruction was discussed with Staff 17 (Interim Administrator), Staff 15 (LPN), and Staff 18 (RCC) on 12/20/22. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs, provided clear direction to staff regarding the delivery of services, and/or were reviewed and updated when residents experienced a significant change of condition for 2 of 2 sampled residents (#s 6 and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 02/2015 with diagnoses including dementia.Observations, interviews, and review of Resident 7's clinical record, including service plans, MARs dated 11/05/22 through 12/19/22 and progress notes dated 11/05/22 through 12/19/22, identified the following:During the acuity interview on 12/20/22, the facility reported Resident 7 experienced a recent change of condition following a hospital stay related to a fall which resulted in a hip fracture. The facility reported Resident 7 returned to the MCC facility on 12/16/22, with high ADL care needs and required one to two staff members to assist with transfers and bowel/bladder management.During interviews on 12/20/22, Staff 9 (MT) and Staff 16 (CG/MT) stated prior to the resident's hospitalization s/he was independent with most ADLs, but upon return to the MCC facility the resident required one to two staff members to assist with transfers. Staff stated they were providing bowel and bladder care while the resident was in bed, as s/he was not able to transfer out of the bed. Staff 16 stated the resident was able to transfer to a wheelchair one time on 12/19/22, with staff assistance.Review of Resident 7's service plan dated 11/29/22, and "Bedside Individual Service Plan" dated 12/20/22, revealed the resident was independent with transfers, ambulation, and toileting and required reminders from staff for dressing and grooming. There was no documented evidence the service plans had been updated to reflect the resident's significant change in condition and change in care needs when the resident returned from the hospital and/or the service plans did not provide clear direction to staff related to the following care areas:* Transfer assistance needs;* Bowel and bladder management needs;* Management and monitoring of surgical incision;* Dressing assistance needs;* Ability to remember to use call light; and* Fall risk related to recent fall resulting in a hip fracture.The need to ensure service plans were reflective of residents' care needs, provided clear direction to staff regarding the delivery of services, and were updated when residents experienced a significant change of condition was discussed with Staff 17 (Interim Administrator) and Staff 15 (LPN) on 12/20/22. They acknowledged the findings.
OAR 411-05-0036 (1-4) Service Plan: General1. Service plans will be updated to reflect current needs and preferences. 2. Executive Director will review 5 service plans a week for memory care to ensure all needs have been addressed.3. Executive Director will have 1:1 weekly with the RSN/LN to ensure move in, COC and quarterlies are done timely. 4. Upon COC, quarterly evaluation or additional assessment, the Expressions Director, RSN/LN will interview care staff for hands on transcription of care to the service plan. 5. Service plans will include personal choices, preferences and needs to be person-centered and specifically relevant to the individual resident. 6. Staff will be in-serviced/educated on who, how, when and why to report resident changes.7. 5 days weekly, RSN/LN, RCC and Executive Director will meet to review the service plan schedule and schedule of completion will be determined at that time.8. The Executive Director, Expressions Director and/or RCC will communicate with the RSN/LN to ensure that move in assessments, quarterlies and COC service plans are meeting regulations and Prestige policy.

2. Resident 1 was admitted to the facility in 03/22 with diagnoses including dementia.Interviews with staff, observations of the resident, and review of the resident's 05/31/22 service plan, 04/26/22 through 06/26/22 temporary service plans, progress notes, and incident investigations were reviewed.Resident 2 experienced the following changes of condition between 04/01/22 and 06/26/22: * 04/05/22: Injury fall with cut on head requiring stitches,* 04/09/22: Injury fall with two abrasions on back, and* 04/10/22: Injury fall with cut on head.The need to ensure residents who had short-term changes of condition were monitored at least weekly to resolution was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training) on 06/29/22. No further documentation was provided.
Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were monitored to resolution at least weekly for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia. Interviews with staff, observations of the resident, and review of the resident's 05/31/22 service plan, 04/26/22 through 06/26/22 temporary service plans, progress notes, and incident investigations were reviewed.Resident 2 experienced the following changes of condition between 04/26/22 and 06/26/22: * 05/25/22: Resident to resident altercation;* 05/28/22: Two vascular wounds on the left leg and one on the right leg;* 06/01/22: Skin tear right arm and left wrist; and* 06/11/22: Cut on head and skin tear to the left elbow.There was no documented evidence the facility monitored the changes of condition to resolution at least weekly. The need to ensure residents who had short-term changes of condition were monitored at least weekly to resolution was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training) on 06/29/22. No further documentation was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was performed for all residents who had significant changes of condition, with interventions communicated to staff and service plans updated for 1 of 1 sampled resident (# 2) who experienced a significant change of condition. Findings include, but are not limited to:Resident 2 was admitted to the facility in December 2021 with diagnoses including dementia.Review of the resident's clinical records indicated that on 05/18/22, Resident 2 experienced a fall which resulted in a left hip injury and pain. The record indicated that after the fall, the resident was unable to ambulate and used a wheelchair for mobility. Resident 2 was observed multiple times during survey sitting in a wheelchair. Staff provided assistance for all wheelchair mobility. Staff 10 (MT) reported on 06/28/22 that prior to the fall, the resident did not use a wheelchair, but was able to stand and walk around independently. Since the fall, Staff 10 stated the resident was able to stand with assist for toileting and transfers but was no longer able to walk. This constituted a significant change of condition. There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition. The need to ensure an RN assessment was completed for all residents with a significant change of condition was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in Training) on 06/29/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included medication-specific parameters for PRN medications for 1 of 2 sampled resident (#2) whose MARs were reviewed. Findings include, but are not limited to:Resident 2's 05/01/22 through 06/26/22 MAR was reviewed and revealed the following: * PRN Morphine Sulphate and PRN Lorazepam were both ordered for symptoms including shortness of breath. The MAR lacked medication-specific parameters for how to determine which medication to administer for shortness of breath. * PRN Acetaminophen was ordered in both liquid and suppository forms for mild pain/fever. The MAR lacked parameters for how to determine which medication to administer for mild pain/fever.The need to ensure MARs were accurate and included clear parameters for PRN medications was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN), and Staff 4 (ED in Training) on 06/29/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behaviors and anxiety had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 1 of 1 sampled resident (#2) who was prescribed PRN psychotropic medications. Findings include, but are not limited to:Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia.Review of the resident's 05/01/22 through 06/26/22 MAR and current physician orders showed the following psychotropic medications:* Lorazepam 0.5 mg (a psychotropic medication) every two hours as needed for anxiety, restlessness or shortness of breath.The facility administered the Lorazepam to the resident on four occasions in May 2022.* Haloperidol 0.5 mg (a psychotropic medication) every two hours as needed for nausea, hallucinations, agitation or delirium.The facility administered the Haloperidol on 16 occasions between 05/01/22 and 06/26/22.The MARs did not contain resident specific parameters for staff describing how the resident expressed anxiety, restlessness, agitation, hallucinations and delirium. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medications. The need to ensure there were resident-specific descriptions of how the resident expressed anxiety, restlessness, agitation, hallucinations and delirium and that non drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in Training) on 06/29/22. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to complete an Acuity-Based Staffing Tool (ABST) assessment for each resident and develop the facility's staffing plan based on the ABST. Findings include, but are not limited to:During entrance on 09/21/22 the ABST assessment was reviewed with Staff 3 (Regional RN). She confirmed the ABST tool was in use for determining the facility's staff plan.The ABST tool showed four residents had information entered into the system for determining the staffing plan, however, the facility census was 17.Staff 3 acknowledged the tool was incomplete, and 13 residents residing in the facility had not yet had information entered into the ABST. The need to complete an accurate assessment of each resident and promptly enter the information into the ABST was reviewed with Staff 4 (ED) and Staff 3 on 09/21/22. No further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation for 2 of 2 sampled residents (#s 6 and 7). This is a repeat citation. Findings include, but are not limited to:During the acuity interview on 12/20/22 it was reported that Residents 6 and 7 required increased ADL assistance due to significant changes of condition which affected their ADL care needs.Reviews of Resident 6 and 7's service plans, 11/05/22 through 12/20/22 progress notes, interviews with multiple care staff, and observations of the residents were completed.The ABST failed to accurately reflect Resident 6's current ADL care needs in the following areas: * Time spent transferring in or out of bed or chair:* Time spent on ambulation, escorting to and from meals;* Time spent supervising, cueing, or supporting while eating; and* Time spent on non-drug interventions for behaviors. The ABST failed to accurately reflect Resident 7's current ADL care needs in the following areas:* Time spent on monitoring of physical conditions;* Time spent transferring in or out of bed or chair;* Time spent on bowel and bladder management;* Time spent on dressing or undressing; and* Time spent on responding to call lights.The need to ensure the ABST tool was reviewed and updated with a significant change of condition was discussed with Staff 17 (Interim Administrator), Staff 15 (LPN), and Staff 18 (RCC) on 12/20/22. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to meet requirements for fire and life safety drills, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Review of facility records on 06/28/22 with Staff 6 (Maintenance Director) identified the following:*There was no documented evidence that fire drills were conducted on alternating months.On 06/28/22 the need to ensure all requirements were met for fire and life safety drills and instruction, in accordance with the OFC was discussed with Staff 1 (ED). He acknowledged the findings.

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 C 260 and Z 155.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure 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 260 and C 361.

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 242 and C 420.
Based on 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 361, C 420 and C 455.


Based on 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 361 and C 455.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff completed the required number of annual in-service training hours. Findings include, but are not limited to:Staff training records were reviewed with Staff 2 (ED Support) on 06/28/22.There was no documented evidence Staff 9 (MT), hired 10/10/16 and Staff 12 (MT), hired 06/07/17 completed the required number of annual in-service training hours.The facility's failure to ensure staff completed the required number of training's annually was discussed with Staff 1 (ED) on 06/28/22. He acknowledged the findings.

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 C 252, C 260, C 270, C 280, C 310 and C 330.
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. This is a repeat citation. Findings include, but are not limited to:Refer to C 260.


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. This is a repeat citation. Findings include, but are not limited to:Refer to C 260.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans, or were followed for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose MCC service plans were reviewed. Findings include, but are not limited to:Resident's 1, 2, 3 and 4's current service plans were reviewed during survey. Each of the service plans lacked information, staff instructions related to individualized nutrition and hydration status and needs, or were not followed by staff members providing care.The need to develop individualized service plans addressing residents' nutrition and hydration needs, and ensure that any plans that were in place were followed, was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training) on 06/29/22. No further documentation was provided.

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident, and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 4 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2 and 4's service plans offered some information about the residents' interests, but the facility had not fully evaluated the residents':* Current abilities and skills;* Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary.Observations on 06/27/22 and 06/28/22 showed multiple residents wandering the halls and residents seated in the TV area for extended periods of time without consistent interaction or intervention from staff. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities.The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training) on 06/29/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 5 sampled residents (#1) with documented behaviors. Findings include, but are not limited to:Resident 1 was admitted to the facility in 03/22 with diagnoses including dementia.Resident 1's record revealed documented behaviors including exit seeking by attempting to leave the unit through the locked door, hitting staff when redirected, verbal outbursts, touching other residents, and following them into their rooms without permission.The resident's service plan, dated 04/21/22 lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 06/29/22 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training). They acknowledged the findings.