Magnolia Gardens Memory Care

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs, provided clear instruction to staff, and/or were readily available to staff for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the memory care community in 03/2025 with diagnoses including Alzheimer’s disease, rheumatoid arthritis, and anxiety disorder. On 02/03/26 it was observed that the resident’s most recent service plan, dated 01/25/26, was not available to care staff in the service plan binder. In an interview on 02/03/26 at 2:30 pm, Staff 1 (Memory Care Director) acknowledged that the service plan available to staff, dated 12/18/25, was not reflective of Resident 1’s care needs, based on the most recent evaluation completed 01/25/26. The need to ensure service plans were readily available to staff was discussed with Staff 1 (Memory Care Director), Staff 3 (RN), and Staff 5 (Campus ED) on 02/04/26 at 1:45 pm. They acknowledged the findings.? 2. Resident 2 was admitted to the facility in 12/2025, with diagnoses of dementia, depression, and urinary tract infection (UTI). Review of Resident 2’s service plan, dated 01/14/26, interim service plans (ISPs), interviews with staff, and observations during survey revealed the service plan was not reflective or did not provide clear direction to staff in the following areas: * Meals, nutrition, and food/fluid preferences; * Use of “scoop plate” for eating; * Adaptations and strategies for activities; and * Proper cleaning and use of CPAP machine. On 02/04/26 at 11:50 am, the need to ensure service plans were reflective and provided clear instructions to staff was discussed with Staff 1 (Memory Care Director) and staff 5 (Campus ED). They acknowledged the findings.

1.What actions will be taken to correct the rule/violation for each example/resident? Resident #1: -The most current service plan dated 1/25/26 was immediately place in the service plan binder in the memory care area. -The service plan was reviewed by the LN(s) and Memory Care Director to ensure all elements from the most recent evaluation were incorporated and clearly outlined what services are provided, by whom, when, how, and how often. -All care staff were notified of the updated service plan during shift change meetings. -A copy of the updated service plan was offered to the resident's legal representative. Resident #2: -The service plan was revised to clearly reflect: *Meal preferences and nutritional needs *Use of scoop plate during meals that has since been discontinued *Specific activity adaptations and engagement strategies *Detailed CPAP cleaning instructions, includes who provides the service, frequency, and procedure steps. -The updated service plan was placed in care staff binder and reviewed with direct care staff. -A copy of the updated service plan was offered to the resident and/or legal representative. 2. How will the system be corrected so this violation will not happen again? -Systemic changes to ensure deficient practice does not occur The facility has implemented the following system changes: (A) service plan availability process -A standarized process was implemented requiring: 1. Immediate replacement of outdated service plans in the care binder upon completion of any update 2. A "Service Plan Update Checklist" to be completed by Memory Care Director or designee verifying: -Binder copy updated -Electronic copy updated -ABST elements updated -Staff notified -Copy offered to resident/legal representative 3. The Memory Care Director or designee will verify completion within 24 hours of update. (B) Quarterly and Significant Change Tracking -A service plan tracking log has been implemented to monitor: *Move-in service plans *30 and 60 day reviews *Quarterly reviews *Significant change updates -The Memory Care Director will review the tracking log weekly (C) Staff Education -The Memory Care Director and LN(s) will provide in-service training to all care leadership on: *OAR 411-054-0036 requirements *Incorporation of person-centered service plans *Clear service direction (who, what, when, how, and how often) *Readily available plans *ABST alignment requirements -Direct Care Staff were educated on accessing and following current service plans -New hires will receive training on service plan requirements during orientation. (D) Administrator Oversight -The Administrator has reaffirmed responsibility under OAR 411-054-0036(2)(g) for ensuring implementations of services -Monthly QA review of 5 randomly selected service plans will be conducted to verify compliance. 3. How often will the area needing correction be evaluated? -The LN(s) or desginee will conduct: *Weekly audits of newly updated service plans for 30 days. *Monthly random audits of at least 5 resident service plans thereafter for 3 months -Audit results will be reviewed in the facility's QA meetings -Any identified concerns will result in immediate correction and re-education -Monitoring will continue at admission, 30 days, 60 days, Quarterly and longer if compliance is not sustained. 4. Who will be responsible for seeing that the corrections are completed/monitored? Memory Care Director: Christina Sexton Licensed Nurse(s): Brie Mendoza RN, Lesli Allen LPN Administrator: Melissa Kozey or Designee.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

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

Based on interview and record review, it was determined the facility failed to notify the physician/ or other legally recognized practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 1 and 2) who had documented medication refusals. Findings include, but are not limited to: The 01/01/26 through 01/31/26 MARs for Residents 1 and 2 were reviewed. Both residents’ records showed multiple medication refusals. There was no documented evidence the facility notified the prescriber when the residents refused to consent to the orders. In interviews on 02/03/26, Staff 1 (Memory Care Director) and Staff 2 (Memory Care Manager) acknowledged the refusals had not been reported to the residents’ physicians. On 02/04/26 at 11:50 am, the need to ensure the facility notified the physician when a resident refused medication was discussed with Staff 1 and Staff 5 (Campus ED). They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each cexample/resident? -The LN(s)/Memory Care Direcor reviewed all documented medication refusals for January 2026. -The prescribing practictioners for both residents were notified on 2/4/26 of the documented refusals, including frequency and pattern of refusals -Documentation of practictioner notification was entered into the residents’ clinical records, including date, time and method of communication -Each resident’s service plan was reviewed and updated as appropriate to reflect: *History of medication refusals *Interventions to address refusals *Clear instructions to staff regarding documentation and notification requirements 2. How will the system be corrected so this violation will not happen again? -The facility has implemented the following corrective systems: (A) Medication refusal reporting protocol A written “Medication Refusal Notification Protocol” was implemented requiring: 1. All medication refusals to be documented on MAR at time of occurrence 2. The medication coordinator to notify the prescriber: a. For ongoing refusals per prescriber direction 3. Documentation in the progress notes to include: a. Date/time of refusal b. Medication refused c. Interventions attempted d. Date/time and method of prescriber notification e. Prescriber instructions or follow up when received (B) Shift to shift communication -Medication refusals will be reviewed during weekly clinical stand up or shift report to ensure timely follow up. -Memory Care Director or designee will review 24-hour reports daily for documented refusals (C) Staff Education -Medication Coordinators receive in-service education on *OAR 411-054-0055 (1) (j-k) requirements *Residents’ right to refuse medications and treatments *Mandatory prescriber notification requirements *Proper documentation standards -Education will be incorporated into new hire orientation for all Clinical Managers and Medication Coordinators. (D) Leadership Oversight -The LN(s) or designee will conduct weekly MAR audits for 30 days to ensure: *Refusals are documented *Prescriber notifications occur timely as directed by provider *Documentation is complete -The Administrator (Campus ED) will review audit findings monthly through QA meetings for 3 months. 3. How often will the area needing correction be evaluated? -Weekly MAR audits -Monthly random audits of 5 resident MARs for 3 months -Findings will be reviewed in IDT meetings -Additional training will be provided immediately if non-compliance is identified -Monitoring will continue until substantial compliance is sustained. 4. Who will be responsible to see that corrections are completed/monitored? Memory Care Director: Christina Sexton Licensed Nurse(s): Brie Mendoza RN, Lesli Allen LPN Administrator: Melissa Kozey Or designee

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

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

Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions were attempted, with ineffective results, prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 1 and 2) who had documented administrations of PRN psychotropics. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2025, with diagnoses including dementia, depression, and urinary tract infection (UTI). Review of Resident 2’s MAR, dated 01/01/26 through 01/31/26, revealed the resident was prescribed two PRN psychotropic medications. These were: * Haloperidol 2mg/ml, for “nausea, restlessness, agitation”; and * Lorazepam 0.5 mg, for “anxiety.” The MAR revealed multiple administrations of PRN Lorazepam. There was no documented evidence that non-pharmacological interventions were attempted with ineffective results, prior to administering the psychotropic. In an interview on 02/03/26 at 12:55 pm, Staff 10 (Lead Med Tech) showed the surveyor the electronic record of PRN psychotropic administrations for Resident 2. Staff 10 acknowledged the lack of documentation of non-drug interventions attempted. On 02/04/26 at 11:50 am, the need to document non-pharmacological interventions tried without effective results prior to administration of a PRN psychotropic medication of a PRN psychotropic medication was discussed with Staff 1 (Memory Care Director) and Staff 5 (Campus ED). They acknowledged the findings. 2. Resident 1 moved into the memory care community in 03/2025 with diagnoses including Alzheimer’s disease, rheumatoid arthritis, and anxiety disorder. Review of Resident 1's 01/01/26 through 01/31/26 MAR and corresponding physician orders showed the following: * Haloperidol 2 mg/ml solution take 1 ml (2mg) by mouth every 6 hours as needed for agitation/hallucinations; and * Lorazepam 0.5 mg tablet give 1tablet every 2 hours as needed for anxiety/dyspnea. Between 01/01/26 and 01/31/26, the resident was administered the PRN haloperidol two times and the PRN lorazepam 17 times. There was no documented evidence non-pharmacological interventions had been attempted with ineffective results prior to administering the PRN psychotropic medications. There were no written resident-specific parameters to instruct staff as to how the resident displayed agitation, anxiety, or hallucinations. The need to ensure documentation of resident-specific parameters and non-pharmacological interventions attempted with ineffective results prior to administering a PRN psychotropic medication was discussed with Staff 1 (Memory Care Director) and Staff 3 (RN) on 02/04/26 at 1:45 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each cexample/resident? -The MARs, Progress Notes, and Service Plans for Residents #1 and #2 were immediately reviewed by LN and Memory Care Director -Resident specific parameters for PRN Psychotropic medications were obtained from the prescribing provider and added to the physician orders for both residents -The LN updated each resident’s service plan to include: *Clear behavioral descriptions that warrant PRN use *Required non-pharmacological interventions to attempt prior to administration *Documentation requirements -All medication staff will be re-educated regarding: *Documentation of non-pharmacological interventions attempted prior to PRN administration *Documentation of ineffective results before administering PRN psychotropics *Proper documentation in electronic record. -A medication documentation audit was completed for January to February 2026 to ensure no additonal undocumented PRN psychotropic administration occurred. Residents #1 and #2 are now compliant with OAR 411-054-0055 (6). 2. How will the system be corrected so this violation will not happen again? The facility has implemented the following systemic corrections: (A) Policy Revision -The Psychotropic Medication policy was revised to: *Require documented non-pharmacological interventions prior to PRN administration *Resident specific parameters for all PRN psychotropics used for behavior. *Clarify that PRN psychotropics may not be used for staff convenience. *Include documentation standards consistent with OAR 411-054-0055 (6) (c) and (f). (B) Documentation Protocol -A mandatory electronic documentation field has been added reequring staff to document: *Specific behaviors observed *Non-pharmacological interventions attempted *Resident response *Rationale for medication administration -PRN psychotropic medication cannot be signed off in MAR until documentation is completed (C) Staff Education All direct care staff, medication coordinators, nurses and leadership reeceived in-service training on: *OAR 411-054-0055 (6) requirements *Use of non-pharmacological interventions *Appropriate PRN psychotropic use *Side effects and when to notify a healthcare professional *Resident specific parameters New hires will receive this training during orientation before being authorized to administer medications. 3. How often will the area needing correction be evaluated? -The LN(s) or designee will conduct: *Weekly audits of all PRN psychotropic administations for 30 days *Monthly audits thereafter for 3 months -Audit results will be reviewed in IDT meetings -Any variances will result in immediate retraining and corrective action 4. Who will be responsible to see that the corrections are completed/monitored? Memory Care Director: Christina Sexton Licensed Nurse(s): Brie Mendoza RN, Lesli Allen LPN Administrator: Melissa Kozey Or Designee

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

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

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month and recorded according to the Oregon Fire Code (OFC) and to ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Upon survey’s entrance to the facility on 02/02/26, fire and life safety records for the past six months were requested. The following was determined: a. The facility lacked documented evidence unannounced fire drills were conducted and recorded at least every other month. b. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills. On 2/04/26 at 10:30 am, Staff 1 (Memory Care Director) and Staff 6 (Building Services Director) confirmed the facility’s lack of documentation of fire drills and fire and life safety training for staff. The need to ensure fire drills were conducted every other month according to the OFC and staff were provided fire and life safety instruction on alternate months was discussed with Staff 1 and Staff 6 on 02/04/26 at 10:40 am. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each cexample/resident? -Immediate Correction *A fire drill was conducted on 2/5/26 with full activation of the alarm system and documentation meeting OAR 411-054-0090 requirements. *Fire and Life Safety in-service training conducted for all current staff. *Any staff not present received 1:1 make-up training. 2. How will the system be corrected so this violation will not happen again? -A standardized Fire Drill Report Form has been implemented to ensure that all required elements are documented: *Date and time *Location of simulated fire *Escape route used *Problems encountered *Evacuation time *Staff on duty and participating *Number of occupants evacuated -A Fire and Life Safety Training Attendance Log has been implemented for alternate month instruction. 3. How often will the area needing correction be evaluated? -Fire Drill Schedule -A 12 month fire drill calendar has been developed to ensure: *Unannounced drills are conducted every other month *Drills occur at varying times (day, evening, night shifts) *Alternate exit routes are used -Alarm activation will occur during each drill unless otherwise directed by the Fire Authority. -Alternate-Month Training -Fire and Life safety instruction will be provided during months when drills are not conducted. -Training will include: *Evacuation procedures *Staff roles and assingments *Use of alternate routes *Resident evacuation assistance *Review of designated points of safety 4. Who will be responsible to see that the corrections are completed/monitored? -Designation of Responsible Party -The Building Services Director (Ty Von Bargen) is responsible for scheduling and conducting fire drills. -The Memory Care Director (Christina Sexton) is responsible for ensuring alternate-month fire and life safety instruction is completed. -The Administrator (Melissa Kozey) has ultimate oversight responsibility.

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

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

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

1. What actions will be taken to correct the rule violation for each example/resident? -A fire drill compliant with OAR 411-054-0090 was conducted on 2/5/26, including activation of the fire alarm system and full documentation of required elements. -Fire and life safety instruction was provided to all current staff. -Any staff not present received make-up training. -All documentation has been reviewed and organized to ensure accessibility and completeness. 2. How will the system be corrected so this violation will not occur again? To ensure compliance with both Division 54 and Division 57 rules: (A) Compliance Tracking System -A 12-month regulatory compliance calendar has been implemented to track: *Every other month unannounced fire drills *Alternate-month fire and life safety instruction *Required documentation elements -The calendar includes assigned responsibility and due dates. 3. How often will the area needing correction be evaluated? -Fire drill and training compliance will be reviewed monthly for 6 months -After 6 months of sustained compliance, monitoring will occur quarterly though QA program -Any missed or incomplete requirement will be corrected immediately, and retraining provided as necessary. 4. Who will be responsible to see that the corrections are completed/monitored? Building Services Director: Ty Von Bargen Memory Care Director: Christina Sexton Administrator: Melissa Kozey

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

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

Based on 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, C305, C310, and C330.

1. What actions will be taken to correct the rule violation for each cexample/resident? -All ressidents’ records were reviewed by LN(s) and Memory Care Director to ensure: *Assessments are current *Service Plans reflect resident needs *Physician Orders are current and accurately transcribed *Monitoring documentation is complete -Any identified discrepancies were corrected immediately. -Staff directly involved received 1:1 retraining regarding: *Assessment updates *Service Plan implementation *Documentation standards *Health status monitoring and reporting -The LN(s) conducted a focused review of residents with higher acuity needs to ensure appropriate heatlh care services are being delivered. 2. How will the system be corrected so this violation will not happen? To ensure compliance with OAR 411-057-0160 (2) (b) and Division 54 health care requirements: (A) Clinical Oversight Strengthened -The LN(s) will conduct a weekly review of: *New move ins *Residents with condition changes *Incident Reports *High-risk residents -Monthly comprehensive chart audits will be completed for a minimum of 10% residents (or at least 5 charts) (B) Assessment & Service Plan Monitoring -A tracking log has been implemented to monitor: *30 and 60 day reviews *Quarterly updates *Significant change assessments (C) Medication and Treatment Oversight -Monthly MAR audits will be completed by LN(s) or designee -Any discrepancies will result in immediate correction and retraining. (D) Staff Education -All care staff will receive refresher training on: *Health status monitoring and reporting *Documentation requirements *Scope of practice *Following physician orders -All new hires will receive reinforced training during orientation regarding Division 54 health care service requirements. 3. How often will the area needing correction be evaluated? -The Memory Care Director will review clinical audit findings once monthly for 6 months -Findings will be discussed during IDT meetings -Patterns or repeat concerns will result in correction action plans. 4. Who will be responsible to see that the corrections are completed/monitored? Memory Care Director: Christina Sexton Licensed Nurse(s): Brie Mendoza RN, Lesli Allen LPN Administrator: Melissa Kozey

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

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and included in the service plans, for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: Current service plans for Residents 1, 2, and 3 were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. On 02/04/26 at 11:50 am, the need to develop individualized service plans which addressed residents' nutrition and hydration needs was discussed with Staff 1 (Memory Care Director) and Staff 5 (Campus ED). They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each cexample/resident? -The LN(s) and Memory Care Director reviewed Residents #1, #2, and #3 -Individualized nutrition and hydration interventions were added to each resident’s service plan, including: *Dietary preferenes *Texture modifications (if applicable) *Hydration supports and monitoring *Cueing or assistance level required *Adaptive utensils (if applicable) -A full audit of current resident service plans was completed to ensure nutrition and hydration needs are individualized and documented. -Any identified gaps were correcteed immediately -Staff were educated on updated service plans and individualized supports. 2. How will the system be corrected so this violation will not happen again? (A) Standardized Assessment Process -Service Plan(s) were updated with Nutrition and Hydration information to ensure the following are addressed: *Resident food preferences *Cultural considerations *Assistance level *Swallowing or chewing concerns *Hydration risk factors *Weight monitoring needs *Adaptive equipment needs *Environmental supports (visual contrast) (B) Visual Contrast Requirement (OAR 411-057-0160 (2)(c)(A)) -The facility reviewed dining settings to ensure: *Plates contrast with table surfaces *Utensils contrast with plates when possible -Dining room setup will be monitored daily by the Memory Care Director or desginee. (C) Adaptive Equipment (OAR 411-057-0160(2)(c)(B)) -Residents are evaluated for adaptive utensils upon move-in and with any significant change. -Adaptive equipment needs are documented in the service plan -Adaptive utensils are readily available during meal times. 3. How often will the area needing correction be evaluated? -The LN(s) will conduct monthly weight reviews -Residents at nutritional risk will be reviewed weekly during IDT. -Service plans will be reviewed 30 and 60 days, Quarterly and with any significant change. -The Memory Care Director or designee will audit 10% of service plans monthly for 3 months to ensure nutrition and hydration needs are individualized and documented. -Findings will be reviewed in IDT meetings. -Any identified deficiency will result in immediate correction and retraining. 4. Who will be responsible to see that the corrections are completed/monitored? Memory Care Director: Christina Sexton Licensed Nurse(s): Brie Mendoza RN, Lesli Allen LPN Administrator: Melissa Kozey Or designee

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

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

Based on interview and record review, it was determined the facility failed to evaluate the residents for activities and develop an individualized activity plan based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose activity plans were reviewed. Findings include, but are not limited to: On 02/03/26 at 1:30 pm, Staff 13 (Life Enrichment Coordinator) reported she did not have activity evaluations for Residents 1 and 2 that included all of the following required components: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for participation; and * Activities that could be used as behavioral interventions. There was no individualized activity plan developed for each resident based on his/her activity evaluation which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities. The need to develop individualized activity plans which were based on an evaluation of the resident's interests, abilities, and needs was discussed with Staff 13 on 02/03/25 at 1:30 pm and with Staff 1 (Memory Care Director) on 02/04/25 at 1:45 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each cexample/resident? -Residents received comprehensive activity evaluations that include: *Past and current interests *Current abilities and skills *Emotional and social needs and patterns *Physical abilities and limitations *Adaptations necessary for participation *Identification of activities for behavioral interventions. -Individualized activity plans were developed for each resident based on their evaluation. *Plans specify what activities will be offered. *When and how often activities will occur *Level of assistance or cueing required *Behavioral interventions supported through activities. -A full audit of all current resident records was completed to ensure: \ *Activity evaluations are complete *Individualized activity plans are developed and reflect evaluation findings. -Any missing components are corrected immediately. 2. How will the system be corrected so this violation will not happen again? A revised Activity Evaluation Form has been implemented that requires documentation of all regulatory components under OAR 411-057-0160 (2)(d)(A), including: *Interests (past and present) *Skills and abilities *Emotional and social patterns *Physical capabilities and limitations *Necessary adaptations *Activities for behavioral support 3. How often will the area needing correction be evaluated? -Evaluations will be completed: *Upon move-in *Within 30 and 60 days * With significant change *At least Quarterly -The Memory Care Director will audit 10% of activity evaluations and plans monthly for 3 months -The administrator will review compliance during IDT meetings. -After 3 months of sustained compliance, monitoring will occur quarterly. -Any identified deficiency will result in immediate correction and retraining. 4. Who will be responsible to see that the corrections are completed/monitored? Life Enrichment Coordinator: Alieah Stinson Memory Care Director: Christina Sexton Administrator: Melissa Kozey

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

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

Based on observation, record review, and interview, it was determined the facility failed to maintain the kitchen and food service areas in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main kitchen and memory care food storage and service areas on 02/04/26 from 10:15 am through 1:15 pm revealed the following: 1) Main Kitchen 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: * Interior of microwave; * Blender base; * Drain under prep sink; * Movable metal speed rack in walk-in cooler; and * Stationary metal racks in walk-in cooler: b. The following areas needed repair: * Reach-in beverage cooler not holding at 41 degrees F or below; * Microwave with multiple areas of rust on ceiling/corners; * Blender base with rust; and * Prep sink pipe without appropriate air gap with pipe observed sitting inside the drain causing potential back-flow contamination hazard. c. Multiple potential hazardous food items were observed opened or prepared without dates. Entire container of dished tartar sauce cups dated 1/29 were noted eight days past prepared dates and should have been discarded. A container of multiple bags of boiled eggs were dated 1/27, ten days past prepared date, and should have been discarded. d. Multiple dished containers of ice cream were observed stored in the reach-in freezer that were not covered/protected from potential contamination. A box of frozen hamburger patties was observed open to potential contamination. e. Multiple staff drinks were observed stored in the walk-in cooler next to resident food, posing potential cross contamination risk. f. Reach-in beverage cooler storing juices and milk was observed to be at 58 degrees F. The temperature of the milk was also found to be at 58.2 degrees F. Staff 2 (Culinary Services Director) acknowledged the cooler should be at 41 degrees F or below. Staff 2 did not know how long the cooler was not holding at appropriate temperatures. Staff 2 indicated they could not locate temperature logs for that cooler for the month of February. 2. Memory Care Food Storage and Service Area 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: * Interior of microwave; * Interior of oven; * Interior of magic bullet blender base; * Interior of cupboards and drawers; * Interior of reach-in refrigerator and freezer; and * Interior of ice machine. b. The following areas needed repair: * Reach-in refrigerator nearest dining room not holding at 41 degrees F or below; and * Interior of cupboard holding clean dishes with section of porous wood exposed. c. Multiple potentially hazardous food items were observed in both reach-in refrigerators that did not have a date opened. Multiple food items were found past seven days, including sliced cheese and lunch meat, and should have been discarded. d. Reach-in refrigerator nearest the dining room thermometer was observed at 50 degrees F. The temperature of some milk from that refrigerator was checked and found at 48.6 degrees F. Temperature monitoring logs for that fridge were reviewed and found with only three days recorded for January 2026 and zero days for February 2026. On 01/05/26 there was a reading of 50 degrees F recorded. Staff 2 was interviewed and was unaware of any concerns with any refrigerators in the memory care unit having temperature issues. e. The dish machine in the memory care unit was a chemical sanitizing machine. Care staff were asked for test strips to test the chemical concentration of the machine. Staff did not know where any test strips were located. Staff indicated they did not test the machine, that the maintenance department tested it. Maintenance was contacted and the machine was tested and was not found to have any chemical sanitizing agent register after multiple cycles tested. Maintenance staff were asked how frequent the machines were tested and they indicated monthly. The machine had to be primed for an extended amount of time before any chemical sanitizer registered. Maintenance staff verified facility staff was not currently testing the dish machine. Staff 2 verified that kitchen staff were not testing the dish machines to ensure sanitation levels were met. Staff 2 verified that resident cups and glasses were washed in that machine after each meal. f. A trash can was observed in the memory care service area. The trash can had visible food and trash debris in the can. The trash can did not have a lid and was not in use. g. A large container of sugar was observed stored with the lid off exposing the contents to potential contamination. Staff 2 toured the main kitchen with surveyor and acknowledged the areas identified. At approximately 1:00 pm, the surveyor reviewed areas of concern for both the main kitchen and memory care areas with Staff 1 (Executive Director) and Staff 2. Both Staff 1 and Staff 2 acknowledged the above areas that needed to be cleaned and/or repaired and practices that needed to be addressed.

1 – Main Kitchen- All items mentioned have been replaced, repaired, fixed and clean. New microwave ordered- blender replaced – drain under prep sink- cleaned and repaired. Racks were cleaned – reach in beverage cooler serviced and repaired All food items with no open dates or out-of-date range were discarded . All food item not covered, ie ice cream, frozen hamburger patties were discarded Staff drinks were removed from residents’ food . Temp logs are now on all fridges with current to date recordings. A-Memory Care food storage and service area- All items listed have been Replaced, fixed, clean and repaired- microwave cleaned , oven cleaned, blender cleaned deep clean kitchen survey. Fridge cleaned B- Items have been repaired , fridge was replaced , cupboard was repaired C- no open dates on items were discarded , items past seven days were discarded , D- fridge was replaced, milk discarded. Temp logs are now current and up to date E- Dishwasher sanitation is now being tested with strips , to test chemicals . F- trash can now had a lid. G- Sugar is now stored in the container with lid on. 2. DSM educated staff on food safety protocol, open dates, temps, proper storage, items needing to be covered. Temp logs are on all fridges and current-to-date recordings. DSM will have on going Kirchen meetings to provide education, training and oversight on labeling, food storage, temps, general cleaning, and overall kitchen compliance as needed no less than 2 times a month Dishwasher sanitation is checked weekly and as needed. 3. DSM will ensure items are in compliance, daily, weekly and monthly. Temp logs are checked daily and will have follow up as needed. Fridge temps checked daily and will have follow up as needed. Dishwasher sanitation is checked weekly and as needed. Daly cleaning task list has been created , wipe down fridge, microwave, oven , cupboards , sweep, mop. New daily task sheet have been created to ensure compliance and check daily by DSM and or designee. ED will follow up once weekly to ensure kitchen compliance 4. DSM and MCD will ensure kitchen compliance ED will provide oversight.

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

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

Based on observations, record review, 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.

See 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.

The findings of the on-site investigation, conducted 12/07/23  are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

The findings of the on-site investigation, conducted 12/07/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the memory care "Servery" on 05/24/23 at 11:15 am through 2:30 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Exterior and interior of range/oven; * Interior of refrigerator and freezer; * Interior of cupboards and drawers; * Utility carts; * Floors in corners, edges and under equipment; * Area behind sink; * Interior and exterior of microwave; * Tops of both reach in refrigerators/freezers; * Coffee maker machine; and * Sponge/scratcher used to clean dishes with visible dried food debris. b. The following areas were found in need of repair: * Caulking around countertops with dirt and possible mold accumulation; * Area under sink near counter top with mold accumulation; c. Cups of ice cream in freezer were stored uncovered. Item in refrigerator found without cover and no date or label. d. Clean rags used for cleaning and sanitizing surfaces were observed stored under sink next to plunger and chemicals and were not protected from potential contamination. e. Dishwashing rack was found stored on the floor. f. There were no strips to monitor the concentration of the dishwasher chemical used to sanitize dishes to ensure effective sanitation. g. Ice machine found with visible mold build up on interior of ice machine. h. Temperatures of food items received from main kitchen were not at required 135 degrees Fahrenheit for hot foods or 40 degrees or under for cold. Staff heated plates in microwave but temperatures did not reach required 165 degrees for reheating as required. Staff were unaware of reheat temperature requirements and served food items under the required temperature requirements. Chicken was reheated to 162.4. A large bowl of macaroni salad was delivered to the servery on top of the hot cart and sat there until ready for service. Temperature was 50 degrees. Staff placed in refrigerator for approximately 10 minutes before platting and serving. Staff did not recheck temperature to see if it had reached the required 40 degrees or lower needed for service. Meal temperature logs were reviewed and revealed multiple entries for the month of May where temperatures were not meeting requirement and no documented follow up to the identified food items under the required temperatures. Staff was interviewed and indicated they would heat the food to above the 135 before service. Records reviewed found 18 food items in May that were documented under the 135 degrees required without documented indication of what action was taken to ensure appropriate temperatures were reached prior to service to residents. There were also multiple missing temperatures for multiple days. i. Staff were observed to wash hands in a sink where dishes were stored for cleaning. Staff did not have a designated area to wash hands. Staff were observed to not wash hands as required when switching tasks, going from dirty to clean, and touching potentially contaminated items. Multiple staff were observed handling the mouth contact and food contact portion of straws with their bare hands that were potentially contaminated from touching door knobs, handles etc. j. Staff were not sanitizing thermometer in between checking temperatures of food items. Staff was observed to "rinse" thermometer under water and wipe with paper towel. k. Clean dishes stored in hallway not protected from potential contamination. In an interview, Staff 2 (Dining Service Manager) acknowledged the identified areas needing addressed. Records of temperatures from main kitchen revealed temperatures were appropriate when food items left the main kitchen. Staff 2 indicated that the hot cart may not be holding appropriate temperatures causing food temps to drop under desired/required levels. Staff 2 verified staff should be reheating the food items to 165 or above if found under 135. Staff 2 verified macaroni salads and other cold items should immediately be placed in the refrigerator until right before service in order to maintain appropriate temperatures. Staff 1 (Executive Director) and the surveyor reviewed the areas in need of cleaning, repair and incorrect practices. S/he acknowledged areas of concern.

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 findings of the kitchen inspection, conducted 5/24/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 05/24/23, conducted 08/22/23, 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.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 01/10/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 01/10/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 01/10/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 01/10/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on record review and interview, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include: Compliance Specialist (CS) reviewed the Uniform Disclosure Statement (UDS) that reflects Shift Hours 6am-2pm Direct Care Staff 3 Medication Aid 1, 2pm-10pm Direct Care Staff 3 Medication Aid 1 and 10pm-6am Direct Care Staff 1 Medication Aid 1. CS reviewed the staff schedule for the month of December 2022. On 12/05/22 S1 stated current census was 31. CS reviewed ABST for 12/05/22 which shows the following: ABST reflects that not all residents are currently entered into tool. ABST reflects AM/day shift includes 30 residents (AM total care hours 24.23 and require a total of 4 caregivers/med-techs), PM/evening shift 29 (PM total care hours 21.8 and require a total of 3 caregivers/med-techs) and Graveyard shift 30 (Graveyard total care hours 8.92 and require a total of 2 caregivers/med-techs) out of current census 31 that require assistance with all activities of daily living (ADL) scheduled and unscheduled care needs. Current Resident Roster includes 32 residents in the facility. ABST does not represent or included all 22 ADL's for scheduled and unscheduled daily care needs for each of the 30 residents entered into tool. Review of residents #1-3 service plans (SP) reflects that not all residents' care needs are reflected in ABST acuity, therefore staffing hours are not calculated to reflect current resident care needs. R3's SP shows resident is on a complex medication regime for daily medication management; also requires follow up interventions after receiving medication for side effects daily. R3's SP reflects resident is bladder incontinent and requires extensive care daily. The above care mentioned is not reflected in ABST and is listed as PRN for daily required scheduled care needs.   In separate interviews with Staff #1 (S1), they stated they had been working hard to get all resident entered into system. They stated at quarterly review, staff is entering all ADL's for residents in ABST. S1 stated they cannot just remove ADLs from the service plans or the Acuity Based Staffing Tool (ABST) unless there is an evaluation done. The nurse or the administrator can only make changes by completing an evaluation in the Blue Step program. The evaluation or change in service would then carry over to the service plan and then be updated in the ABST. On 12/05/22, these findings were reviewed with and acknowledged by S1.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 12/05/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 10/11/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 7/14/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview, observation and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include: Review of staffing schedules for June and July 2022, posted staffing plan, ABST summary, and service plan for Resident #1. The ABST shows the facility needs 5 caregivers (CG) and 1 med tech (MT) for Days and Swing shift, and 1 CG and 1 MT for NOC shift. The posted staffing plan shows that they have 2.5 CG and 1 MT for Days and Swing shifts, and 1 CG and 1 MT for NOC shift. CS observed that the facility is staffed below their staffing as reported on the ABST on 07/07/22. The posted staffing plan has not been updated with the current staffing levels from the ABST. The above information was shared with Staff #1 on 07/07/22, who acknowledged the findings. In an interview on 07/07/22, Staff #1 stated that the facility is using their own ABST. It pulls information (for the required ADLs) straight from the service plans to determine their acuity and staffing levels. They are not currently staffing to the new staffing levels as they do not have the staff to do so. They are currently hiring and are in the process of training new staff. Resident #1 missed their scheduled appointment due to the facility not getting them ready on time. Plan of Correction: The facility is hiring more staff and currently training new hires, they will staff per the ABST and update the posted staffing plan, and hope to have a specific person for showers, transportation, and coordinating appointments when fully staffed.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 7/7/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview and record review, it was confirmed that the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include: Review of staffing schedules for June and July 2022, posted staffing plan, Acuity Based Staffing Tool (ABST), service plans and progress notes for Resident #1, and the appointment calendar. The facility is not staffing per the ABST. Interviews on 07/07/22, Staff #1 stated that the facility is using their own ABST. They are not currently staffed per their acuity. They are in the process of hiring and training staff. Currently the admin assistant is the person scheduling appointments and setting up transportation for residents. The resident missed their first appointment because ride source cancelled, and they had to reschedule because their maintenance director was off that day, and they don ' t have anyone else that can drive the bus. The second appointment was missed because the resident was not ready to go on time. They had to reschedule the appointment. Staff should be assisting the residents and making sure they are ready for their appointments. Plan of Correction: Hiring and training new staff, staffing per the ABST and updating the posted staffing plan. They would like to have a specific person for showers, transportation, and appointments when they are fully staffed.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 07/07/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation, interview and record review, it was determined the facility failed to provide effective oversight to ensure quality of care and services that were rendered in the facility. Findings include, but are not limited to: During the survey, conducted 02/15/22 through 02/17/22, administrative oversight to ensure adequate resident care and quality of services rendered in the facility were found to be ineffective based on the number of citations. Refer to deficiencies in report.

ED will complete 40 hour admin class and apporoved administrator course required for Oregon Health licensing. The community will hire an outside state approved consultant to provide additional oversight and training and oversight the new leadership team through the next 4-6 weeks. Quartley reivew of systems and on going quality assurance will be reviewd with ED and ops support. Operations support and Mosaic Management.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to: Observations during survey, conducted 02/15/22 through 02/17/22, multiple Oregon Department of Human Services (ODHS) infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. The following issues were identified: * The facility was not consistently screening visitors or outside providers upon entering the building; * Staff were unaware of the screening procedure for visitors; * The PPE cleaning and storage area was disorganized with scattered PPE and garbage containing used PPE was uncovered and overfilled; * A used face shield was found on a shelf in the dry food storage area; * A caregiver was observed touching her mask multiple times without subsequent use of hand sanitizer or washing hands. That same caregiver was observed in the serving area preparing snacks for the residents without wearing any PPE; and * The facility failed to ensure residents were assisted with hand hygiene throughout the day. The need to ensure the facility practiced effective methods of infection control and conducted regular auditing of those practices was discussed with Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.

All staff will be required to take the Oregon Care Partners COVID precautions class online. All staff will be provided training on reporting signs and symptoms of COVID along with what actions need to be taken when a resident exhibits signs or symptoms of COVID. All staff will be retrained on the procedures for screening visitors upon entering the community. All staff will be retrained on the proper guidelines for donning and doffing face shields. Information will also be posted in all break rooms and will be reviewd monthly at all staff meetings. The ED will provide oversight.

2. The following observations were made during the lunch meal on 07/18/22: * Staff 20 (MT) failed to sanitize her hands between residents when she passed medications. * A resident was observed to touch the handle of a communal water dispenser with her hand and the spout with her used glass. Care staff and Staff 14 (ED) were apprised immediately of the potential for the spread of infection related to the use of the communal water dispenser. The need to ensure reasonable precautions were exercised against any condition that could threaten the health, safety or welfare of the residents was discussed with Staff 14, Staff 12 (Operations Personal Support), Staff 15 (Home Office RN), Staff 3 (Administrator Assistant), and Staff 16 (Resident Services Manager) on 07/20/22. They acknowledged the findings and reported the communal water dispenser had been removed.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. This is a repeat citation. Findings include, but are not limited to: 1. The use of medical masks by all staff is required during the COVID-19 pandemic. On 07/18/22, Staff 16 (Resident Services Manager) was observed without a mask on while eating food inside an office with an unsampled resident present. On 07/18/22, the need to ensure all staff were appropriately and consistently using Personal Protective Equipment during the COVID-19 pandemic was discussed with Staff 14 (Executive Director) and Staff 16. They acknowledged the findings.

All staff will follow proper infection control precautions while caring for residents.  The communal water dispenser was removed during visit and will not be reinstated. All staff will be in-serviced on the necessity of wearing masks appropriately and consistentley as requiered Managers will round on the floor daily and monitor proper infection control practices are being followed.  Immediate education will be provided and documented for any staff found not following proper infection control precautions. Executive director or designee will be responsible for ensuring compliance.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to: a. The servery of the Memory Care Community was toured on 02/16/22. The following areas were in need of cleaning or repair: * Food splatters and particles inside the refrigerator and microwave;   * Undated opened foods and condiments in the refrigerator; * Debris on bottoms of drawers and cabinet shelves; * Accumulation of dust and debris along perimeter of the baseboards; and * Unfastened kick plate below the stove. b. Meal service for the Memory Care unit was observed on 02/17/22 at 12:30 pm. Food was cooked at the main kitchen in the Assisted Living Building. The food was covered with aluminum foil, and transported on a pushcart to the unit, where it was served and plated to the residents. Staff reported they were unable to use the heated meal cart for it required two people for maneuvering and they both could not leave the building. The lunch meal temperatures were not taken prior to serving the residents. Three unsampled residents reported the food was not always hot when served, excessive wait times for meals, menus not being offered and condiments such as butter were not provided with the meals. The findings and concerns were reviewed with Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.

The kitchen will receive a deep clean by the new dining manager and team. Daily, weekly and monthly cleaning tasks sheets will be implemented to include daily sign off by the kitchen team. The Dining Manager will assure completion daily. The ED will inspect the kitchen weekly with the new Dining Manager to assure compliance. The ED will complete a weekly on one meeting with the new Dining Manager to assure compliance is being met. The new Dining Manager has been provided training offsite and will implement the weekly QA programs in the kitchen and complete his own weekly QA. The Dining Manager will have a kitchen team meeting weekly for the next 4 weeks and 2 times monthly after to provide training and oversight to general cleaning, food storage, labeling and overall kitchen compliance needs. The new Dining Manager will track food delivery times for the next 4 weeks to assure and evaluate the delivery times. This will be evaluated daily at stand up with all managers and the ED. Meals will be tempted prior to serving from the steam tables to the residents and tracked on the temperature charts. The new Dining Manager will review temperature charts daily to assure compliance is met. The Dining Manager will implement a QA tool that requires that cooks taste all meal prior to being served and review all dining feedback cards with the team. All staff will receive retraining on proper handwashing, and this will be observed by the new Dining Manager daily and observations tracked on the Dining Manager weekly QA followed by a weekly one on one meeting with the Dining Manager.   The ED will provide oversight.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations addressed all required elements and included accurate and sufficient information to develop an initial service plan to meet the resident's needs, for 1 of 1 sampled resident (#3) whose initial move-in evaluation was reviewed. Findings include, but are not limited to: Resident 3's initial move-in evaluation, dated 01/31/22, failed to address the following required elements: * Personality, including how a person copes with change or challenging situations; and * Environmental factors that impact the resident's behavior including, but not limited to: Noise, lighting, room temperature. The new move-in evaluation was reviewed with Staff 2 (RN), Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.

Resident 3 service plan and evaluation has been updated to include personality, including how this resident cope with change or challenging situations to include environmental factors that impact the resident's behavior including noise lighting and room temperature. All resident service plans and evaluations will be audited to assure that all these areas are addressed in in each service plan. The leadership team will receive additional training in regard to the move in evaluations requirements. Initial, Quarterly, and COC. The ED will provide oversight.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed.  Findings include, but are not limited to: Resident 1 and 2's most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director) and Staff 3 (RN) on 02/16/22. They acknowledged there was no service planning team.

The management team will meet each Wednesday and review all service plans that are due and complete the QA tool that is labeled Interdisciplinary Team Meeting. All Managers will be required to attend. Service plan reminder letters will be mailed to families, caseworkers and residents at the beginning of each month with a proposed time and date to review the service plan. All current families, residents and caseworkers will be given a copy of their current service plans. Initial, 30 day, Qaurterly and COC. The ED will provide oversight.

Based on observation, interview and record review, it was determined the facility failed to provide sufficient numbers of caregiving staff to meet the 24 hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care. Findings include, but are not limited to: The facility was an endorsed Memory Care Community home to 35 residents at the time of the relicensure survey. During the acuity interview on 02/15/22 the facility was identified to have residents with high ADL care needs, behavioral interventions and dementia diagnoses. The MCC Staffing Plan posted on the wall indicated two caregivers and one med tech per day and evening shift and one caregiver and one med tech for the overnight shift. During observations and interviews, it was revealed that staff were not direct caregivers, but universal workers. In addition to caregiving and medication duties, staff were observed to provide: * Housekeeping; * COVID-19 Infection Control procedures; * Laundry service for all residents; and * All meal service including, preparing, serving, delivering, cleaning, and providing hydration and snacks throughout the day. The regulation required that if a facility used universal workers, whose duties included other tasks (i.e., housekeeping, laundry, food service, etc.), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services. That number was not increased to meet resident needs. Staff 3 (Admin Assistant) was asked during the survey if she could provide a copy of the facility's procedure for determining appropriate staffing levels. A screen shot of the current acuity report was provided. The acuity report failed to evaluate residents ADL care needs and service needs and the facility's procedure to determine staffing levels based on the calculated number was not provided. Observations and interviews during the survey on 02/15/22 through 02/17/22 revealed the following: * No activities were offered. At times, a television was left on in the dining room and living room; * There was no designated activity worker on the unit and there was no available activity calendar or schedule; * Multiple residents wandered the halls confused and two residents were observed to go in out of other resident's rooms; * Multiple residents had a disheveled appearance; * Residents' meals were cooked from the main kitchen in the Assisted Living Building. Caregivers were responsible for transporting the food from main kitchen to the MC. Caregivers were unable to use the heated meal cart because it took two people to maneuver and there was not enough staff to leave the building. A regular pushcart was used. Caregivers had to dish out the food individually on plates, serve to the residents, clean up after the meals and do the dishes; * Unsampled resident interviews during the lunch meal on 02/17/22, expressed the following concerns: long wait times for meals, residents waiting so long in the dining room, they get up and walk away, by the time the food gets here, it is always cold, and there's only one caregiver serving the dining room; and * An interview with a caregiver reported, she had left work at 3pm last week and the residents had still not received their lunch. The need to ensure sufficient number of caregiving staff to meet the 24 hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care was discussed with Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. No additional information was provided.

The community will initiate the staffing acuity tool provided by the state until an in-house tool is approved for use. A complete review of resident acuity will be completed by shift to assure appropriate staff are scheduled to work to meet the scheduled and unscheduled needs of the residents. Staff turnover will be evaluated weekly by the ED and management team at every level. Exit interviews will be conducted for all staff that are termed. The Community will have a staffing agency contract in place for emergency use. Dining room attendants/servers will be added to the staffing plan for the kitchen. A laundry attendant that focuses on resident laundry will be added to the staffing. An activity calendar has been posted. This will be reviewed and updated daily depending on resident needs. The ED will provide oversight.

Based on interview and record review, it was determined the facility failed to ensure the minimum staffing requirement, per the condition placed by the Department of Human Service on 6/14/22, to ensure the 24-hour scheduled and unscheduled needs of the residents were met, was satisfied. This is repeat citation. Findings include, but are not limited to: The 06/14/22 condition per the Department of Human Service required the facility to have three care partners and one medication technician on both the day and swing shifts, and one care partner and one medication technician on the night shift. The posted staffing schedule on 07/18/22 indicated the facility staffed 2.5 care partners and one medication technician on the day and swing shifts. Staff 10 (Care partner), Staff 19 (MT), and Staff 21 (Care partner) reported during interviews on 07/18/22 and 07/19/22 that they were often short-staffed on the day and swing shifts. Review of the 07/10/22 through 07/17/22 staffing schedule and payroll records revealed the facility failed to meet the required the minimum staffing requirements on the following dates and shifts: 07/10/22: Day and swing shifts; 07/11/22: Day shift; 07/12/22: Day and swing shifts; 07/13/22: Swing shift; 07/16/22: Swing shift; and 07/17/22: Day and swing shifts. The failure of the facility to ensure the minimum staffing requirements to ensure the 24-hour scheduled and unscheduled needs of the resident were met per the condition placed by the Department of Human Service on 06/14/22 was discussed with Staff 14 (ED) Staff 12 (Operations Personal Support), Staff 15 (Home Office RN), Staff 3 (Administrator Assistant) and Staff 16 (Resident Services Manager). No further documentation was provided.

Facitily will ensure staffing levels are met per the acuity based staffing tool. Community is actively hiring through ads on indeed, communicating with agency to meet any shortages. Staff shcedules will be reviewed daily at stand up to ensure adequate staffing levels are met. Executive director or designee will be reponsible for ensuring proper staffing levels.

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. Findings include, but are not limited to: Fire and life safety records for August 2021 through January 2022 were reviewed with Staff 4 (Maintenance) on 02/17/22 . Staff 4 revealed the facility did not relocate or evacuate the  residents during the monthly fire drills. Therefore, documentation was lacking regarding the escape route used, residents who resisted or failed to participate in the drills, evacuation time period needed, and number of occupants evacuated. The need to evacuate residents during fire drills unless there was documented evidence an alternative fire drill plan had been developed with the Oregon Fire Authority and documentation of the fire drills included all necessary components was discussed with Staff 3 (Admin Assistant) and Staff 4 on 02/17/22. They acknowledged the findings.

The ED and Maintenance Manager will receive training on the rules regarding the requirements for fire drills by the Director of Environmental Services at Mosaic. Moving forward, documentation of resident participation and routes of evacuation will be reviewed by ED after each fire drill. Monthly ED will provide oversight.

Based on interview and record review, it was determined the facility failed to provide evidence that evacuation assistance to residents from the building to a designated point of safety were used during fire drills, that staff were aware of the designated point of safety, and that residents received training about the facility's fire and safety procedures within 24 hours of move in and annually. Findings include, but are not limited to: Fire and life safety records reviewed on 02/17/22, for August 2021 to January 2022 lacked the following components: * The facility was not evacuating residents to a designated point of safety during fire drills; * Interviews with staff on 02/17/22, revealed they did not consistently know the designated point of safety; and * There was no documented evidence the facility was instructing residents on fire and life safety procedures within 24 hours of move in and annually. The need to ensure the facility provided evacuation assistance to residents to a designated point of safety, and residents received training about the facility's fire and safety procedures was discussed with Staff 3 (Admin Assistant) and Staff 4 (Maintenance) on 02/17/22. They acknowledged the findings.

The ED and Maintenance Manager will receive training on the rules regarding the requirements for fire drills by the Director of Environmental Services at Mosaic. All staff will be trained on alternate evacuation routes and proper fire drill policy and procedures. Monthly ED will provide oversight.

Based on observation and interview, it was determined the facility failed to ensure the interior was clean and in good repair. Findings include, but are not limited to: Observations and interviews during the survey on 02/16/22 and 02/17/22 identified the following: * Carpet throughout the common areas and hallways had spots and stains; * Multiple resident doors and walls had splatters, drips, and chips; * Furniture throughout the facility including chairs, benches and tables had stains; * The lower aspect of the kitchenette bar counter located in the living room had pieces missing along the base exposing wood; * The utility/laundry room needed to be cleaned and sanitized; * Room 9 had pieces of ceiling caulk that had fallen onto the carpet. Staff 4 (Maintenance) stated there had been a leak from the ceiling and they were in the process of fixing it and they would move the resident until it was fixed; and * Room 16 had sputum on the walls, floor, and bed. Staff reported the resident does this all over his/her room on a daily basis and they have tried many interventions; however, the resident continues the behavior. Housekeeping routinely cleans the room and the facility was working on getting housekeeping help on the days the housekeeper was off. The areas in need of cleaning and repair were reviewed and discussed with Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.

Carpets are scheduled to be cleaned and are added to a monthly cleaning schedule. All touch up paint is scheduled to be completed. The utility room has been cleaned. Weekly cleanliness QA walk through program has been implemented. A housekeeping checklist to report repairs will be implemented so that each apartment in the community is reviewed weekly for repair needs. Room 9 is scheduled for caulking repair. Room 16 is scheduled for a deep cleaning and evaluation of the resident's appropriateness is underway. Faciltiy walk throughs will be implimented daily. The ED will provide oversight.

Based on observation and interview, it was determined the facility failed to have an operational call system that connected residents' units to the care staff.  Findings include, but are not limited to: On 02/17/22, the surveyor tested room two's call system. After ten minutes, the surveyor walked out of the room and asked staff 5 (MT/Care partner) how they were alerted to residents call lights. Staff 5 stated the staff carry a fob that shows a call light was activated. When asked if there was an alert for room two. She stated she did not have a fob. Staff 5 went into the room where the fobs were kept, and the two fobs were on the counter unplugged and not charged. Staff 5 proceeded to charge them. There were no other fobs available for staff. The need to ensure the facility provided a call system that connects residents units to care staff was discussed with Staff 3 ( Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.

Contacted Ciscor, our call system company. All residents have been entered into the system. BOM is entering in all staff members for correct log in information. We have more Ipods for our notifications in route. ED went into Ciscor and seperated Assisted Living and Memory Care pull cord calls. BOM will be entering in all new staff and residents into the system as soon as they are hired or moved into the facility. All managers, during walk throughs are going to ensure that all staff have their Ipods on them and are logged into the system. ED, RN, BOM will have Ciscor on their laptops and will be able to hear and see all resident calls that are going off. This will be reviwed daily from several managers during our daily routine walk throughs. ED will provide oversight.

Based on observation and interview, it was determined the facility failed to have an operational call system that connected residents' units to the care staff. This is a repeat citation. Findings include, but are not limited to: On 07/18/22, Staff 19 (Care partner) was asked to activate a resident call light. After activating a call light, Staff 19 explained that the call system alerts iPods, but that only one was currently available and was charging. In addition, Staff 19 reported that many staff did not have the ability to log in to activate the iPod. The activated iPod was found beeping on the charger in an empty room behind a closed door. Staff 17 (Care partner) and Staff 21 (Care partner) reported they were not carrying iPods connected to the call system. The need to ensure the facility provided a call system that connected residents' units to care staff was discussed with Staff 14 (Executive Director) on 07/19/22. She acknowledged the findings.

Community has an operational call system that connects resident units to care staff. All care staff have been in-serviced on use of the call system.  All staff have been re-instructed on log in and password for use of call system. Random auidts will be done by maintenance to ensure staff are using the ipods. Administrative assistant/RSM will train all new staff on the use of the ipods. Execuitve Director or designee will be responsible for ensuring staff are using the call system

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 150, C 160, C 240, C 360, C 420, C 422, C 510, C 513 and C 555.

Refer to C150, C160, C240, C360, C420, C422, C510, C513, C555

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 160 , C 360 , C 455 and C 555 .

Refer to C 160, C 360, C 455 and C 555

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired direct care staff (#s 9, 11 and 13) had documentation of demonstrated competency in all required training topics within 30 days of hire. Findings include, but are not limited to: Review of staff training records on 02/17/22, identified Staff 9, 11, and 13 (Carepartners), hired on 12/13/21, 12/06/21 and 12/15/21 respectively, lacked the following documentation of demonstrated competencies within 30 days of hire: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observations, and reporting. The need to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire was discussed with Staff 3 (Admin Assistant) on 02/17/22. She acknowledged the findings.

Completed full audit on all staff to assurre all new hire paperwork is completed, 30 day check ins are being completed on time. Monthly Audit of employee records, QA tool will be utilized to assure compliance. Monthly ED will provide oversight.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired direct-care staff (#s 19 and 20) had demonstrated competency in all assigned job duties prior to independently providing resident services. This is a repeat citation. Findings include, but are not limited to: Training records were reviewed on 07/19/22. The following deficiencies were identified: 1. Staff 20 (MT) was hired 07/05/22. The Med Tech Training Skills Checklist was signed by Staff 20 on 07/18/22 and had not been signed by the trainer. Staff 20 was observed independently passing medications on 07/18/22 and 07/19/22. The survey team received a signed note on 07/19/22 from Staff 14 (ED) stating Staff 20 would not pass medications independently until the trainer had completed the Skills Checklist. 2. Staff 19 (MT) was hired 06/07/22. The Med Tech Training Skills Checklist was signed on 07/11/22 by Staff 19 and by a trainer on 07/19/22. Staff 19 was on the Staff Schedule 07/03, 07/04 and 07/10 as an independent Med Tech. Staff 19 was observed independently passing medications on 07/18/22. The need to ensure all newly-hired staff demonstrated competency in all assigned job duties prior to independently providing resident services was discussed with Staff 14 (Executive Director) and Staff 16 (Resident Services Manager) on 07/19/22. They acknowledged the findings.

All staff who work independently will have demonstrated compentecy within 30 days of hire. Immediately following demonstrated compentecy on a particular task the trainer will sign off on the trainee's checklist All staff records have been audited to assure compentencies are completed and current.  Skills checklist will be reviewed twice monthly Executive Director or designee will audit skills checklist monthly for compliance.

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 and C 262.

Refer to C252 and C262

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 2 of 2 sampled residents (#1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Residents 1 and 2's current service plans were reviewed during survey. The service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.

Full audit of all resident service plans to ensure they all have an individualized nutrition and hydration plan in place. Service planning team will be implimented with ED, RN, other staff, family and the residents. Initial, Quarterly and COC. ED will provide oversight.

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 1 of 2 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to: Resident 1's service plan offered some information about the resident's interests, but the facility had not fully evaluated the resident's: * 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 02/16/22 and 02/17/22 showed multiple residents wandering the halls, one entering other resident's rooms 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 2 (RN) on 02/16/22 and Staff 3 (Admin Assistant) on 02/17/22. They acknowledged the findings.

Refer to tag C262

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to: The MCC was toured on 02/16/22 and 02/17/22. Resident rooms including, but not limited to 10, 11, 12, 14, 15, 16, 18, 20, 21, 22  and 23 lacked any means of identifying the room for the resident. The need to ensure each resident room was identified to assist the resident in identifying their room was reviewed with Staff 3 (Admin Assistant) and Staff 12 (Operations Personal Support) on 02/17/22. They acknowledged the findings.

Mangagers are going to perform daily walk throughs. All resident name plates have been corrected. Facility will indivualize resident shadow box'. Daily walk throughs from managers. Changing name plates as soon as a resident moves in or moves out. Notifying families before a resident moves in, to please assist with making a shadow box for their loved one. Daily, with manager walk throughs. ED will provide oversight.

Based on observation, 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. Findings include, but are not limited to: Refer to C 160, C 360, C 555, and Z 155.

Refer to C 160, C 360, C 555, and Z 155.

The findings of the re-licensure survey, conducted 2/15/22 through 2/17/22, 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 for Home and Community Based Services Regulations. 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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit of the re-licensure survey on 02/17/22, conducted from 07/18/22 through 07/20/22, 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, and 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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 02/17/22, conducted on 02/21/23, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.