Russellville Park Memory Care

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

Based on interview and record review, it was determined the facility failed to ensure management or the licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions, that the service plan was adjusted if necessary, and that reporting protocols were in place for 1 of 1 resident (#2) who received HH services. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2022 with diagnoses including Alzheimer's disease. Staff reported in the acuity interview on 04/20/26 the resident had a history of falls, including an unwitnessed fall with bilateral knee pain, and was currently receiving HH PT services. The resident’s 01/15/26 to 04/20/26 clinical record was reviewed, including HH PT notes. The following was identified: * 03/11/26—HH PT documented the resident’s heart rate was “consistently high[,] above 90 [beats per minute]”; * 03/18/26—HH PT documented exercises were provided for CGs to implement; and * 03/24/26—HH PT documented the resident was discharged from HH PT services. There was no documented evidence facility management or the licensed nurse reviewed the above HH PT notes. There was no documented evidence that reporting protocols were in place to notify facility management or licensed nurse regarding the HH PT report of the resident’s heart rate, the service plan was adjusted with HH PT exercises/recommendations, or that staff were notified of the HH PT discharge. In an interview at 1:46 pm on 04/20/26, Staff 8 (MT) stated outside providers left notes with the MT on shift and verbally spoke with the MTs regarding services provided. She stated, “as far as I know” Resident 2 was still receiving PT services. The need to ensure management or the licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions, that the service plan was adjusted if necessary, and that reporting protocols were in place was discussed with Staff 1 (Administrator/RN) at 11:07 am on 04/22/26. He acknowledged the findings.

OAR 411 054 0045 Resident 1 &2 Service Plan has been evaluated by the RN. Home health noted reviewed and signed service plan now reflective of Outside Provider information. Communication protocol with outside provider reviewed, Nursing/RCC protocols for commnuication reviewed with ED - ED will Audit Quarterly to ensure systems in place ED is responisble to see that corrections are made and monitored

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

Based on observation and interview, it was determined the facility failed to follow established infection prevention and control protocols to ensure a safe, sanitary, and comfortable environment for 1 of 1 sampled resident (#1) whose ADL care was observed and 1 of 1 sampled resident (#2) and multiple unsampled residents whose meal service was observed. Findings include, but are not limited to: 1. Resident 1 moved into the memory care community in 07/2024 with diagnoses including Alzheimer’s disease and dementia. During the acuity interview on 04/20/26, the resident was identified as needing assistance for all ADLs and was “bed bound.” On 04/21/26 at 11:37 am, the surveyor observed Staff 6 (CG) and Staff 13 (MT) assist the resident with incontinence care in his/her bed. Both staff members donned cleaned gloves. Staff prepared for the task by removing a doll, a top sheet, a blanket, and pillows being used to elevate Resident 1’s heels. Staff collected a clean brief and chucks pad, disposable wipes, and barrier cream. Staff unfastened the resident’s briefs and removed the soiled brief while assisting the resident to roll to his/her side on the chucks pad that was under the resident. Staff 13 used wipes to provide perineal care following a small bowel movement. Both staff members assisted Resident 1 to get in the middle of the bed by using the resident’s bottom sheet to slide him/her up. They assisted the resident to roll to the other direction and Staff 6 completed the cleaning task, removed the soiled chucks pad, and threw the soiled brief, chucks pad, and used wipes in the garbage can. Some of the items fell on the floor, so he picked them up and placed those in the garbage as well. Staff 6 changed his soiled gloves at that time. Staff 13 was not observed to change her gloves or perform hand hygiene after the incontinence task had been completed. She was observed to touch a clean sheet, pillows, a blanket, place the doll with the resident, touch the bed remote, and push the bed back against the wall. No hand hygiene had been performed prior to touching the non-soiled items. Staff 6 removed the garbage can liner where the soiled items were put and tied it in a knot. He replaced the liner and doffed his gloves. No hand hygiene was observed prior to Staff 6 and Staff 13 exiting the resident’s room. A housekeeper was observed at approximately 1:30 pm to look inside of Resident 1’s apartment but did not enter the room to clean the area where the soiled items were dropped onto the floor. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (Administrator/RN) and Staff 3 (RCC) on 04/22/26 at 10:45 am. They acknowledged the findings. 2. Observations of meal service conducted on 04/20/26 at 12:00 pm showed the following: Staff 3 (RCC) was observed at the counter of the kitchenette wearing single-use gloves, serving residents, including Resident 2 and unsampled residents, food from large serving pans. While serving, she was observed to eat some of the French fries from one of the pans, as well as drink from a personal beverage located to the left of the serving pans. Wearing the same single-use gloves, she continued to serve residents food. The need to ensure the facility maintained infection prevention and control protocols was discussed with Staff 1 (Administrator/RN) at 11:07 am on 04/22/26. He acknowledged the findings.

OAR 411057 0410 Staff 6&13 giving education regarding Infection Control, Polices and best practice Spot check by Director/RCC weekly Education to be given by Direcor to staff monthly Director/ED to be responsible for ensuring weekly observations and monthly trainings are given

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

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

Based on observation, interview, and record review, it was determined the facility failed to ensure residents had privacy in their own units for 1 of 1 sampled resident (#3) and multiple unsampled residents who lived in the MCC. Findings include, but are not limited to: 1. The MCC included three double occupancy units: 168, 171, and 173. Review of the current resident roster on 04/20/26 showed all three units were 100% occupied. Observations of the rooms made on 04/20/26 showed no method to ensure privacy between the residents’ sections of the unit. Review of Resident 3’s service plan, last updated 04/02/26, showed no documented evidence of a system to ensure privacy in his/her unit. In an interview at 9:25 am on 04/21/26, Staff 6 (CG) stated when providing dressing and other ADL assistance to Resident 3, he had to wait for the resident’s roommate to leave the room to ensure privacy. The need to ensure residents had privacy in their own units was discussed with Staff 1 (Administrator/RN) at 11:07 am on 04/22/26. He acknowledged the findings. 2. The memory care unit was located inside of an assisted living facility. One way to access the unit was to go through the Bistro Café. The café overlooked the assisted living courtyard, and multiple apartment windows were visible. An unsampled resident was observed to reside in the memory care unit, in an apartment that was immediately inside the unit by the main door. On 04/21/26 at approximately 9:45 am, the inside of the unsampled resident’s apartment, located in the memory care unit, was observed from the assisted living facility’s Bistro Café. The blinds inside of the apartment were raised. There were no window coverings observed in the café. On 04/21/26 and 04/22/26, multiple observations were made of the resident in his/her unit, including while s/he was laying in bed sleeping. On 04/22/26 at 11:43 am, Staff 1 (Administrator/RN) and Staff 3 (RCC) confirmed that the unsampled resident was independent in ADLs. On 04/22/26 at approximately 12:55 pm, Staff 2 (ED) confirmed that all the memory care unit apartments had windows that either faced the courtyard accessible to the assisted living facility or to the street. The need to ensure each resident had privacy in his or her own unit was reviewed with Staff 1, Staff 2, and Staff 3 on 04/22/26. They acknowledged the findings.

OAR 411-057-0220 Resident Rights – Privacy A privacy divider has been provided in apartment 168,171,and 173 to support the resident’s privacy needs. The resident 3's service plan has been updated to reflect their preferences regarding privacy. Staff have been educated on resident privacy rights and expectations, including maintaining dignity during care and honoring individual preferences. The RCC or Memory Care Director will review resident preferences for privacy during initial and quarterly evaluations to ensure service plans are updated accordingly. The Memory Care Director or Executive Director will conduct periodic audits to ensure compliance and that resident privacy needs continue to be met.

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

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents had a key to their unit for multiple sampled and unsampled residents. Findings include, but are not limited to: Observations made on 04/20/26 and 04/21/26 showed Resident 2’s door was locked on several occasions, both while s/he was inside and outside of the unit. At 10:22 am on 04/21/26, Resident 2 attempted to open his/her door, and it was locked. S/he stated, “my door is locked.” Staff arrived shortly after and unlocked the door. In an interview at 10:32 am on 04/21/26, Staff 6 (CG) stated Resident 2 would frequently lock his/her door when leaving or entering the unit. He stated s/he did not have a key. In an interview at 2:09 pm on 04/21/26, Witness 1 (Family) confirmed the resident was not provided with a key to his/her unit. In an interview at 12:53 pm on 04/21/26, Staff 1 (Administrator/RN) stated Resident 2 had not been evaluated for his/her ability to manage a key, and had not been provided with a key. He stated families/residents were offered keys as part of the move-in process, but if they declined, they were not provided with one. He confirmed multiple residents did not have keys to their units. The need to ensure residents were provided with a key to their units was discussed with Staff 1 at 11:07 am on 04/22/26. He acknowledged the findings.

OAR 411 004 0070 Resident 2 key access was given to resident 2, Service plan updated to reflect to say Resident has a key and her key use and where it is located Upon admission key policy to be reviewed with family, During Initial evaluation by RCC/Nurse - Service plan updated and key given per preferance Reviewed quarterly during resident evaluations by Director/RCC Evaluations to be reviewed quarterly by ED

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

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

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C295.

OAR 411 057 0140 Education goven to staff regarding infection control polices and best practice - to ensure patient care and cross contaminations is reduced Spot checks by RCC/Director weekly Education to be given monthly by Director to staff monthly Director?ED is responsible for ensuring weekly observation and monthly trainings are given

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 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 9 and 11) completed all pre-service orientation training, all required pre-service dementia trainings, and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 04/21/26 at 1:40 pm. The following was identified: Staff 9 (CG) was hired 02/26/26 and Staff 11 (CG) was hired 02/24/26. a. There was no documented evidence Staff 11 completed orientation in infectious disease prevention. b. There was no documented evidence Staff 9 and Staff 11 completed pre-service dementia training in one or more of the following topics: * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach; * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicated a change in the resident’s condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and * The use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 11 had demonstrated competency within 30 days of hire in: * Identification, documentation and reporting changes of condition; and * Conditions that require assessment, treatment, observation and reporting. On 04/22/26 at 9:04 am, the need to ensure staff completed all required pre-service orientation and pre-service dementia trainings and demonstrated competency in assigned duties within 30 days of hire was discussed with Staff 1 (Administrator/RN) and Staff 3 (RCC). They acknowledged the findings.

OAR 411 057 0155 staff 9+11 completed all trainings required Staff have received required inservice training in Relias and skills orientation checklist completed Annual training to be completed in Relias Relias to be audited by Diector/RCC quarterly

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

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

Based on interview and record review, it was determined the facility failed to 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 C290.

OAR 411 057 0160 (2b) Facility nurse to review all outside provider notes to ensure careplans are updated - reviewed communication and documentation Home health noted reviewed and signed service plan now reflective of Outside Provider information. Communication protocol with outside provider reviewed, Nursing/RCC protocols for commnuication reviewed with ED - ED will Audit Quarterly to ensure systems in place ED is responisble to see that corrections are made and monitored

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

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 07/31/25 at 11:00 am, the facility main kitchen was observed to need cleaning and repair in the following areas: a. Food spills, splatters, debris, dirt, and black matter was observed on or underneath the following: * Knobs and face of oven and grill; * Floor underneath stove and grill; * Multiple floor drains; * Caulking behind hand wash and two-compartment sink; * Wall and pipes under two-compartment sink; * Lids of food bins in dry storage room and food prep area; * Multiple walls throughout; * Three-shelf rolling serving carts; * Flooring and drain in beverage area; and * Floor of dessert fridge. b. The following areas needed repair: * Peeling paint on wall behind sprayer in dish machine area; * Door and jamb to storage room had scraped paint; * Dessert fridge had pooled water on the interior floor. A baking sheet with a towel was placed on the top shelf to catch water dripping from the interior vent; and * Peeling paint in the beverage area next to the right entrance door. c. Observations of food service in the MCC on 07/31/25 at 12:10 pm revealed the following: * Care staff were plating and serving resident’s meals without the use of a protective barrier over potentially contaminated clothing; and * Care staff touched food with bare hands while plating it for the residents. The areas that required cleaning and repair in the facility main kitchen were observed and discussed with Staff 2 (Executive Chef) on 07/31/25 at 11:55 am. He acknowledged the findings. The need to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules was reviewed with Staff 1 (General Manager) during the exit interview on 07/31/25. The findings were acknowledged.

Rule Violated: OAR 411-054-0030 (1)(a); OAR 333-150-0000 A full deep cleaning of the kitchen was completed on August 1, 2025, addressing all areas identified during the inspection. This included thorough cleaning of appliances, walls, floors, sinks, food bins, rolling carts, and the dessert fridge. The baking sheet and towel found inside the dessert fridge were immediately removed and discarded. The maintenance team was assigned the following repairs: • Repainting walls with peeling paint, • Repairing and sealing the damaged door jamb, • Repairing or replacing the dessert fridge to resolve the issue of pooled water. A revised cleaning schedule outlining specific daily, weekly, and monthly responsibilities was implemented effective August 1st, 2025. A cleaning checklist and log are now required to be completed daily and verified by the Executive Chef. Monthly environmental inspections will be conducted by the Administrator or designee to ensure sustained compliance. Responsible Parties: • Executive Chef: Oversees kitchen cleanliness, ensures staff compliance, and verifies daily cleaning logs. • General Manager: Conducts weekly walkthroughs, monitors implementation of the plan, and ensures monthly inspections are completed and systems sustained. • Maintenance Director: Responsible for the timely completion of all kitchen-related repairs and ongoing facility maintenance. • On August 1, 2025, all MCC care staff were immediately re-educated on food safety protocols, including the mandatory use of protective barriers (aprons/gowns) when handling or serving food. • Staff were instructed that bare-hand contact with ready-to-eat food is strictly prohibited and must be replaced with utensil use or single-use gloves. • Supervisors conducted direct observation and coaching during meal service the following day to reinforce correct practices. • Protective disposable aprons were stocked and made easily accessible in the MC dining area. • Effective August 2, 2025, a visual checklist for food safety and PPE use during meal service was posted and implemented in the MC. • A new “Meal Service Compliance Spot Check” log was introduced, requiring supervisors to observe and document adherence to safe food practices during randomly selected meal periods. • Procedures and language updated to clarify that any direct hand contact with food or failure to use protective gear will result in immediate coaching and, if repeated, disciplinary action. MCC Supervisor – Ensures staff wear protective gear and avoid bare-hand contact during service. • General Manager – Reviews compliance data and ensures system is sustained. • Administrator – Ensures quarterly training occurs and that spot checks are evaluated for trends and follow-through.

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

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 05/21/24 at 11:15 am, the facility kitchen was observed to need cleaning in the following areas: a. Food spills, splatters, drips, debris, grease, black/brown matter and/or dust was observed on the following areas: * Shelves below steam table - food debris/spills; * Ice cream freezer - spills on bottom and shelves; * Upright refrigerator - floor with food debris; * Walk in freezer floor - food debris; * Floor under grill/stove - food debris; * Shelves above grill/stove including foil lined shelf with grease and food debris; * Knobs and front of grill/stove - drips and spills; * Interior shelves of refrigerator located on the steam table - plastic worn off, rusted, food debris on bottom shelf and black/brown debris/matter on interior door seals; * Interior of microwave - food debris splatter; * Sides of deep fat fryer, grill/stove - grease/food drips; * Grill top blackened surface and edges; * Upper and lower shelves of prep counters - food debris; * Lids of food storage bins - food debris, sticky; * Ice machine interior - black/pink matter; * Tray under food slicer - food debris/crumbs; * Wall behind sprayer hose in dishwashing area - black matter build up; * Top of dishwasher - debris; * Refrigerator in beverage service area - spills/drips; * Electrical cord of microwave - heavy build up of dust near clean dishes; * Toaster (automatic) - heavily soiled with crumbs; * Four-slice toaster - front covered with debris/drips/spills; * Exterior of convection oven - spills/grease; * Waffle iron - burnt debris sitting on paper lined tray with dried on drips/spills; and * Sprinkler head next to oven/grill hood - heavily accumulation of dust. b. Improper food storage: * Walk in freezer - two stacks of boxes on floor; * Ice cream freezer - one tub of ice cream uncovered; * Walk in refrigerator - shell eggs stored on top of pan of cooked rice which was covered with plastic wrap; * Unlabeled/undated bags of cooked pasta, cut fruit, multiple containers of food items; * Uncovered cooked meat on rolling cart; * Uncovered containers of seasonings/herb on grill shelf; * Refrigerator located on steam table - uncovered/unlabeled food items (salad/asparagus); * Food storage bins containing sugar, flour and panko crumbs had scoops in the products; * Container of uncovered lemon slices was stored on beverage station counter; and * Open/uncovered container of ketchup and closed container of garlic butter were stored on steam table counter. c. Items needing repaired: * Uncovered ceiling lights in dry food storage and entrance to kitchen; and * Drawer fronts on prep counter. d. Other findings: * Two uncovered garbage cans stored near the steam table and * Staff not wearing beard restraints. The findings were discussed and observed by Staff 2 (Chef) and discussed with Staff 3 (General Manager) on 05/21/24. The findings were acknowledged.

C-240 - Following the visit on May 21st, 2024, the Food and Beverage Team has cleaned / corrected each cited item to address the rule violation affecting all residents.   General Manager has reviewed the communities Food Handling Policy with all Food and Beverage Members.  A Sanitation Inspection Form has been established for the community and will be completed on a weekly basis.  The weekly Sanitation Inspection Form will be reviewed by the Chef, who will review the findings and any corrective action plans with the General Manager / designee at the weekly 1:1 GM/Chef meeting and documented using the established meeting agenda template.   The General Manager is responsible to see that the corrections are completed and monitored.

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 OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 07/26/24 at 10:45 am, the facility main kitchen located in the assisted living which serviced the memory care community was observed to need cleaning in the following areas: a. Food spills, splatters, drips, debris, grease, black/brown matter and/or dust was observed on the following areas: * Shelves below steam table; * Upright refrigerator; * Floor under grill/stove; * Knobs and front of grill/stove had buildup of drips and spills; * Sides of deep fryer and grill/stove; * Upper and lower shelves of prep counters; * Wall behind sprayer hose in dishwashing area had black matter build up above and below the counter; * Exterior of convection oven - spills/grease; * Vulcan oven interior had a build up of food debris; * Ice cream freezer had old ice cream packaging beneath open ice cream containers; and * Food storage bins containing sugar, flour and panko crumbs had scoops in the products. b. Areas needing repair in the assisted living kitchen:   * Ceiling lights and tiles above the food prep and food service areas were damaged and/or stained; * Drawer fronts on prep counter were broken; * Refrigerator located beneath the steam table had damaged door seals and doors had exposed refrigeration insulation; * The Blodgett convection oven was inoperable; * Holes in the wall surrounding pipes inside the beverage sink cabinets; and * Holes in the wall surrounding pipes in the dish machine area. c. Areas needing repair in the memory care kitchenette: * A cabinet door below the steam table had a broken hinge which prevented the cabinet door to open and close properly. d. Infection control: * Two uncovered garbage cans stored near the steam table; and * Staff not wearing beard restraints. A tour of the kitchen was completed and the findings were discussed with Staff 2 (Chef) and Staff 3 (General Manager) on 07/26/24 at 12:30 pm. The findings were acknowledged.

C-240 - Following the visit on July 26, 2024, the Food and Beverage Team has cleaned / corrected each cited item to address the rule violation affecting all residents. General Manager has reviewed the communities Food Handling Policy with all Food and Beverage Members. A Sanitation Inspection Form and task list has been established for the community and will be completed on a daily basis.  This will be reviewed with the Food and Beverage Team and review of the findings and any corrective action plans will be addressed.  The areas needing repair have been completed by the Facilities Maintenance Team and we have contacted vendors regarding the repair/ replacement costs of the inoperable Blodgett oven.  The General Manager is responsible to see that all corrections have been completed and monitored.

Based on observation 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.

C-240 - Following the visit on May 21st, 2024, the Food and Beverage Team has cleaned / corrected each cited item to address the rule violation affecting all residents.   General Manager has reviewed the communities Food Handling Policy with all Food and Beverage Members.  A Sanitation Inspection Form has been established for the community and will be completed on a weekly basis.  The weekly Sanitation Inspection Form will be reviewed by the Chef, who will review the findings and any corrective action plans with the General Manager / designee at the weekly 1:1 GM/Chef meeting and documented using the established meeting agenda template.   The General Manager is responsible to see that the corrections are completed and monitored.

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

Refer to C 240 POC

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

C-240 - Following the visit on July 26, 2024, the Food and Beverage Team has cleaned / corrected each cited item to address the rule violation affecting all residents. General Manager has reviewed the communities Food Handling Policy with all Food and Beverage Members. A Sanitation Inspection Form and task list has been established for the community and will be completed on a daily basis.  This will be reviewed with the Food and Beverage Team and review of the findings and any corrective action plans will be addressed.  The areas needing repair have been completed by the Facilities Maintenance Team and we have contacted vendors regarding the repair/ replacement costs of the inoperable Blodgett oven.   The General Manager is responsible to see that all corrections have been completed and monitored.

The findings of the kitchen inspection, conducted 05/21/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000 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.

The findings of the first re-visit to the kitchen inspection of 05/21/24, conducted 07/26/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services-Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

The findings of the second revisit to the kitchen inspection of 05/21/24, conducted 09/25/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview and record review, it was determined the facility failed to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and create opportunities for active participation in the community at large. Findings include, but are not limited to: During the survey, the MCC was home to 12 residents. Random resident observations made on 12/06/22 and 12/07/22, review of the activity calendar, and interviews with staff revealed the following: a. The December 2022 Memory Care Activity Program calendar provided during the entrance conference indicated the following activities would occur on 12/06/22: * 9:00 am: News; * 9:30 am: Mini Mani's: * 10:00 am: Painting with Margi; * 11:30 am: Balloon Toss; * 1:00 pm: Fitness with Sam; * 2:00 pm: Baking with Staff; and * 3:30 pm: Mind Game. On 12/06/22, the only facility led activities observed in the MCC between 9:30 am - 3:30 pm was a painting activity. Although television movies and holiday music played sporadically, no other activities were observed. b. On 12/07/22, the activity calendar and a posted daily activity plan (written on a dry erase board in the activity area) noted the following activities would occur: * 9:00 am: News; * 9:30 am: Coloring; * 9:30 am: Craft time; * 10:00 am: Tea time with staff; * 10:00 am: Hydration and snacks; * 11:00 am: Daily Chronicle; * 11:00 am: Fitness with Sam; * 1:15 pm: Puzzle time; * 2:00 pm: Hot cocoa; * 3:00 pm: Holiday Movie; * 3:30 pm: Music Therapy; and * 4:15 pm: Balloon Toss. The only facility led activities observed between 8:30 am - 3:30 pm was a holiday craft where one resident participated, and an afternoon snack of cookies and drinks. The television and holiday music played sporadically; however, no other facility led activities were observed. Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1 (Administrator) on 12/07/22 at 3:30 pm. She acknowledged the findings.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities Staff was inserviced immediately on the importance of following scheduled activties or finding alternate options based on resident interests outlined in service plans. Operations Leader reviewed company standards related to activities in Memory Care with Memory Care Manager and General Manager. Staff training was conducted with all memory care staff related to company memory care programs to provide a daily activity program of social and recreational activities based on individual and group interests, physical. Memory Care manager to conduct a daily audit to ensure scheduled activities are being conducted. General Manager is responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) whose records were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 11/2022. A review of the resident's move-in evaluation failed to address the following: * Customary routines; * Spiritual, cultural preference and traditions; * Personality including how a person copes with change or challenging situations; * Complex medication regimen; * Recent losses; and * Environmental factors that impact the residents behavior, including but not limited to: noise, lighting and room temperature. The facility's failure to complete all required elements for Resident 3's move-in evaluation was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 12/07/22. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move -in and Eval: Resident Evaluation Resident 3 has been reassessed and service plan was updated to reflect complete and accuragte resident care needs. Prior to the residents moving in to Memory Care, the Memory Care Manager, and Health and Wellness Director will review the evaluation- and service plan to ensure it reflects all evaluation elements. Evaluations will be reviewed 30 days after the initial move in and quaterly. Evaluation training was held with the Memory Care Manager and RCC. Evaluations will be audited by the memory care manager monthly and the H&W director, RN. Weekly meeting will be held with GM and Health and Wellness team to audit processes. General Manager will be responsible for overall compliance.

2. Resident 1 was admitted to the MCC in 2020 with diagnoses which included dementia. Interviews with care staff and observations of Resident 1 during the survey revealed s/he was incontinent, received assistance for several ADL care needs, and did not use a call light to summon assistance. Resident 1's service plan, dated 10/19/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas: * Skin rash and treatments; * UTI medication; * Forehead wound; * Activities; and * Use of eye glasses. The need to ensure the service plan was reflective of Resident 1's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 12/07/22 at 3:25 pm. She acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia. Observations of the resident and interviews with staff during the survey, and review of the clinical record including the 12/06/22 service plan and Temporary Plan of Care (TSPs) from 09/01/22 through 12/06/22, revealed the service plan was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas: * Skin condition; * Bathing and shower services; * Use of boots on legs; * Toileting status; * Use of air mattress; * Use of floor mat on each side of bed; and * Ted hose status. The need to ensure the service plan was reflective of Resident 2's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 12/07/22. She acknowledged the findings.

OAR 411-054-0036 (1-5) Service Plan: General Resident 1 & 2 have been evaluated, current health needs, clear direction regarding the delivery of services have been updated and are now reflective of the residents care needs. Resident 1 & 2 now address the needs listed as deficient and those service needs are reflective on the service plan. Resident # 2 has clear direction on hospice care orders in the service plan including the use of the air mattress and the floor mats on each side of the bed. Bathing services updated to reflect hospice care conducting them. Resident #1 has clear direction to reflect the needs and provide direction to the staff on how to deliver the care the resident needs.   Service plan development & training was conducted by the memory care manager with the team. Weekly meeting will be held with GM and Health and Wellness team to audit processes. General Manager will be responsible for overall compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for residents who had significant changes of condition which included documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#2) who experienced a significant change of condition in weight status. Findings include, but are not limited to: Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia and edema. During the acuity interview on 12/06/22, the resident was identified to have a weight change. The resident was observed on 12/06/22 in the dining room for lunch. The resident ate the meal independently and consumed 100 %. Resident 2's weight records were reviewed during the survey and revealed the following: * 01/05/22 - 228.0 pounds; * 06/02/22 - 252.0 pounds; * 08/04/22 - 242.0 pounds; * 11/03/22 - 252.0 pounds; and * 12/01/22 - 232.4 pounds. From 01/2022 to 06/2022, Resident 2 gained 24.0 pounds or 10.52 % of his/her body weight in five months, and from 11/03/22 to 12/01/22, the resident lost 20.6 pounds or 8.51 % of his/her body weight in a month, which represented a significant change of condition. The facility RN completed an assessment on 07/24/22 and stated the "current weight 238 [pounds]" and noted "weight entered on 6/22 is likely data error entry as all other weights are consistent and range for 6 months". However, there was no documented evidence the RN evaluated the resident's weight to support the 06/2022 weight data was an error such as a re-weigh of the resident or obtained the resident's weight in 07/2022. There was no RN assessment for the significant weight loss between 11/2022 and 12/2022 at the time of survey. The need to ensure significant changes of condition were assessed by an RN and the assessment included documentation of findings, the resident's status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 12/07/22. They acknowledged the findings.

OAE 411-054-0045 (1) (a-f) (A) (C-F) Resident health services Resident 2 has been reassessed for Significant Change of Condition for weight change by the RN. The service plan has been updated to reflect those changes. Memory care manager and RN will review notes, incident reports and alerts daily and will have the assessments and service plan updates completed for all the significant change of conditions within 48 hours. Memory Care Manager will review notes, incident reports, and alerts daily and communicate significant change of conditions to RN. All care staff were re-trained on reporting changes for residents per company policy. RN will have assessment and service plan updates completed for all significant changes of conditions within 48 hours. Service Planning and Significant Change of Condition training was conducted by H&W Director and Corporate RN with the nursing team. All care staff were re-trained on reporting changes for residents per company policy using. Weekly meeting will be held with GM and Health and Wellness team to audit processes. Memory Care Manager will be responsible for overall compliance.

3. Resident 6 was admitted to the facility with diagnoses including dementia, HTN and was on hospice. Resident 6's weight record was reviewed during the survey and revealed the following: * 02/2023 - 148 pounds; * 03/2023 - 140 pounds; * 04/2023 - 133 pounds; and * 05/03/23 - 136 pounds. From 02/2023 to 03/2023, Resident 6 lost 8 pounds or 5.4% of his/her body weight. Between 03/2023 to 04/2023, Resident 6 lost another 7 pounds or 5% of his/her body weight, both of which represented a significant change of condition. There was no documented evidence the RN conducted an assessment of the resident's weight loss from 02/2023 through 04/2023, which included findings, a description of resident status and a plan of care to address the weight loss. Resident 6 was observed eating lunch and snacks independently on 05/15/23 and 05/16/23. S/he ate well when placed with other residents who were eating. On 05/11/23, one month after the second significant weight loss, the new facility RN, Staff 12, completed a significant change of condition assessment for the weight loss and included interventions of encourage resident to eat and drink at meal times, encourage resident to snack during the day and remind of all meals. The requirement to document a timely RN assessment of a resident's significant change of condition was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 05/17/23. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for residents who had significant changes of condition, which included documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 1 and 6) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to: Resident 1 was admitted to the facility with diagnoses including dementia and Kidney disease (stage III). Resident 1's record was reviewed during the survey and revealed the following: 1. The MCC "Weight Report" for Resident 1 documented a monthly gain 26 pounds in 04/2023, and then a loss of 17 pounds in 05/2023. *03/2023 179 pounds; *04/2023 205 (26 pound weight gain); and *05/2023 188 (17 pound weight loss). The significant weight fluctuations between 03/2023 and 04/2023 and also 4/2023 to 5/2023 constituted a significant change of condition. In interview on 05/09/23 Staff 1 (Administrator) stated the weight fluctuation were data errors due to staff using different scales for weights, however, there was no re-weigh, evaluation of the weight data, or referral to the RN for assessment of the weight fluctuation. 2. A progress note dated 04/23/23 noted Resident 1 was found on the floor "holding left shoulder stating it hurts terrible", and "called 911 to have resident evaluated." Resident 1's service plan was updated at return from the emergency room to include the information "returned with a broken left collarbone and large skin tear on left elbow". A 04/24/23 progress note documented "resident struggles with transfers since return from the hospital. Often becomes flustered making ADL unsafe for resident and staff". Also on 04/24/23, a note stated "continue to use PRN acetaminophen (pain medicine) and Risperidone (psychotropic medication) every 6 hours for pain and agitation", and on 04/25/23 "Mobility Change: needing two person assist when getting up from dining room chairs". A "RN post-fall note" dated 04/24/23 failed to document or assess the "large skin tear", fractured bone, unsafe ADL, increased pain and PRN pain medication use, mobility changes requiring two person assist, or to update the service plan with fall interventions. The requirement to document an RN assessment of a resident's significant change of condition that included assessment, findings, resident status, and service plan interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 05/17/23. They acknowledged the findings.

C280 - OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident 1 has been assessed by the RN for a significan change of condition for the weight change and a weight monitoring plan of only using the weight chair for weighing not only this resicent but                  all residents is in place. The service plan has been updated to reflect those changes. Memory care manager and RN will review notes, incident reports and alerts daily and will have the assessments and service plan updates completed for all the significant change of conditions within the 48 hours. Memory Care manager and Resident Care coordinators will review notes, incident reports, and alerts daily and communicte those change of conditions to the RN. All the staff have been re-trained on the process of reporting changes for residents per our company policy. The RN will have all significant change of conditions completed withing 48 hours. Service plan and change of condittion training completed by the H&W director as well as the RN with the nursing team. The staff of the Memory care community were trained on reporting changes for the residents per company policy. Weekly meeting is held for the H&W team, GM to discuss residents of concern and ensure compliance is being met. Memory Care Manager will be responsible for the overall compliance.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 1 of 2 sampled residents (#2) who received outside services. Findings include, but are not limited to: Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia and right foot pain. During the acuity interview on 12/06/22, the resident was identified to receive hospice services. Resident 2's clinical record, dated 10/04/22 through 12/13/22, was reviewed during the survey and revealed the following outside provider recommendations: * A 12/02/22 note instructed staff to try to keep "[resident] in bed. Will talk w/[with] provider about course of ABX [antibiotic]"; and * On 12/03/22, a note indicated "if pt [resident] is bedbound, please make sure to reposition Q4H [every four hours] to maintain skin integrity". There was no documented evidence the recommendations were communicated to staff or implemented. On 12/07/22, the need to ensure on-going coordination of care was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator). Staff acknowledged the findings.

OAR 411-054-0045 (2) Res Hlth Srvc: on-and Off- site health srvc. Resident 2 has been evaluated, service plan has been updated to reflect current needs and home health recommendations. Coordinator, Memory Care manager, and RN have been trained to request all notes from Home Health during their visits, if unable to obtain they will call the Home health agency to obtain notes. Home Health/outside provider notes will be reviewed daily by the memory care team as well as the licensed nurse during the clinical meetings and recommendations will be updated in service plan as needed. Coordination of care training has been provided by the health and wellness director. Service Plans will be audited quarterly to ensure HH recommendations are incorporated and updated in service plans. Weeky meeting with GM and Health and Wellness team take place to monitor compliance. Memory Care Manager will be reponsible for monitoring compliance.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month, and fire/life safety instruction was provided to staff on alternating months. Findings include, but are not limited to: On 12/06/22, fire drill and fire/life safety training records for the previous six months were requested. Review of the documentation provided identified the following: * No fire drills had been completed in the MCC during the six-month time frame reviewed; and * No fire and life safety instruction was provided to staff. The requirements regarding fire drills and fire/life safety instruction for staff were reviewed with Staff 1 (Administrator) on 12/06/22 at 2:00 pm. The findings were acknowledged.

OAR 411-054-0090 (1) (a-d) Fire and LIfe Safety: Drills and instruction SOD placed in fire drill binder as the vilation cannot be corrected for past dates. Operations Director has provided fire drill process and documentation education to the plant operations supervisor. Plant operations supervisor will ensure a separate memory care drill and staff training is conducted in compliance with company policy. General manager will audit all fire drills for the memory care monthly and hold weekly meetings with Plant Operations Director to monitor ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission and annually. Findings include, but are not limited to: Fire and life safety records were requested during the survey. The following deficiencies were identified: * Documentation of fire and life safety training provided to residents within 24 hours of move in; and * Documentation of annual fire and life safety training provided to residents. The need to ensure residents received fire and life safety training within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (Administrator) on 12/07/22 at 1:15 pm. She acknowledged the findings. No further information was provided.

OAR 411-054-0090 (5) Fire and LIfe Safety:Training for residents SOD placed in fire drill binder as the vilation cannot be corrected for past dates. Operations Director has provided fire drill process and documentation education to the plant operations supervisor. Plant operations supervisor and or MC manager will ensure resident has been instructed on the procedures per OFC within 24 hours of admission into Memory Care and will be re-insturcted annually. Documentation will be keep to reflect those trainings. Weekly meeting will be held between GM and Plant Operations Supervisor to monitor compliance. General Manager will be reponsible for monitoring compliance.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 242, C 420 and C 422.

OAR 411-057-0140 (2) Administration compliance All staff that will be conducting, monitoring, and reviewing the preceeding tags: C242, C420, and C422 have been instructed and trained on proper protocols to ensure that resident evaluations, service plans, coordination of care, significant change of condition processes meet the licensing requirements for the facility. General Manager and Memory Care Manager will be reponsible for monitoring compliance.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly hired staff (#6) completed all required pre-service training prior to performing any job duties, and 2 of 3 direct care staff (#s 9 and 10) failed to complete a minimum of 16 hours of annual in-service training annually on topics related to the provision of care for persons in a community-based care setting, including six hours of annual in-service training on dementia care. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (Administrator) on 12/07/22. The following deficiencies were identified: 1. Staff 6 (CG) was hired 09/07/22. a. There was no documented evidence she had completed the following elements of the required pre-service orientation and dementia training prior to performing any job duties: * Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach; * Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.) * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and * Use of supportive devices with restraining qualities in memory care communities. 2. Staff 9 (CG) was hired 10/17/19 and Staff 10 (CG) was hired 11/08/19. Review of annual training, based on their anniversary date of hire, revealed the following: a. Staff 9 lacked documented evidence of having completed at least 16 hours of annual in-service training on topics related to the provision of care for persons in a community-based care setting, including six hours related to dementia care. b. Staff 10 lacked documented evidence of having completed at least 10 hours of annual in-service training related to the provision of care for persons in a community-based care setting. Staff training requirements were reviewed with Staff 1 (Administrator) on 12/07/22. She acknowledged the findings.

OAR 411-057-0155 (1-6) Staff Training Requrements: Copy of Sod will be placed in employee file for Staff 6, 9, and 10 and Staff 6, 9, 10 will complete required trainings on Relias and Memory Care Manager has completed their observations for competency. Operations Leader provided training for Memory Care Manager on new hire training process and requirement. All staff that are hired will be required to complete all required relias trainings to meet the licensing rules. Staff will continue to conduct continuing education training throughout the year to meet the required 16 hours of training annually. Memory care manager as well as RCC will check on staff relias training weekly to ensure that trainings are being completed and done on time. Annual training will also be completed using Relias and Relias records will be audited quarterly by Memory Care Manager. Weekly department meeting will be conducted to monitor compliance. The General Manager is responsible to see that the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C 260, C 280 and C290.

OAR 411-057-0160 (2b) Compliance with Rules Health Care Memory care manager as well as RCC & facility RN will ensure that resident routines are identified and in the service plan for the direct care staff to be able to provide the care for the resident. Proper coordination of care is added to the service plan for residents for staff to care for the residents based on their individual care needs and routines. related to C252, C260, C280, C290. Weekly meeting with General Manager and Health & wellness team will be held to monitor compliance. Memory Care Manager will be responsible 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 280.

Z-162 - OAR 411-057-0160(2b)

Based on observation and interview, it was determined the facility failed to have a written facility policy which detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather. Findings include, but are not limited to: During the survey, the following was revealed: * The doors to access interior courtyard were observed to be unlocked during daylight hours on 12/06/22 and 12/07/22; * When the doors were opened, there was no sound to alert staff; and * Staff 11 (Maintenance Director) was unsure about the alert system and the policy detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather. On 12/07/22, Staff 1 confirmed the facility did not have a written policy for when the courtyard doors would be locked. On 12/07/22 at 4:30 pm, during the exit interview, Staff 1 and Staff 3 (ALF Administrator) acknowledged the above findings.

OAR 411-0057-0170 Secure Outdoor Recreation Area. Operations Director reviewed company Opal Key Control policy with General Manager and Memory Care Manager. Doors to courtyard are not locked, they are alarmed 24 hours a day to allow resident access to secured courtyard. When door opens alert of the alarm will be sent to all memory care staff requiring staff to check the courtyard and ensure resident safety. During bad weather staff will be instructed by Memory Care manager to lock courtyard doors to ensure resident safety. Locking mechnaism will be added to courtyard doors. Staff will be inserviced on company Key Control policy which outlines monitoring and securing of enclosed courtyard. Compliance will be reviewed in weekly meetings. Memory Care Manager will be responsible for overall compliance.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 280.

C 455 OAR 411-054-0105 (2-4) refer to C280

The findings of the re-licensure survey, conducted 12/06/22 through 12/07/22, 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 to the re-licensure survey of 12/07/22, conducted 05/12/23 through 05/17/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. 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 12/07/22, conducted 08/01/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

Based on observation 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 333-150-000. Findings include, but are not limited to: Observations of the Assisted Living kitchen with Staff 4 (Cook) on 11/28/22 at 9:30 am, revealed the following: *The kitchen entrance door frame had a chip in the plaster exposing the dry wall underneath; *The dish machine area above the stainless-steel table, had a softball sized hole in the wall; *The dish machine had dried food matter and splattered debris on the sides, front, legs and top;   *The wall directly behind the dish machine and sink beside the dish machine had splattered food, dust and dirt; *Dish Crates around dish station were on floor; *There were boxes on floor in walk-in refrigerator, freezer and dry storage areas; *Shelving in the walk-in refrigerator and freezer had a build-up of dirt and debris; *There was a broken stainless-steel drawer face that had dirt and debris on it; *The ice machine vent, knife holder, wall outside chef's office, door frames, door jambs and Steam and Hold machine had dirt, dust and debris on them; *Two trash cans did not have lids in the area near the stove; * The can opener holder had a build-up of food debris; * The mixer backsplash had a build-up of dried food debris; *The shelf above the stove had a build-up of dirt and debris on it; *The Vulcan stove knobs and handles had sticky matter and dried food debris on them; *Lack of test strips to check sanitizers; *The dry food storage bins had dirt and food matter on their tops and sides; and *Soiled towels were on the floor underneath the bread rack. The surveyor reviewed the above areas needing cleaning and repair with Staff 1 (General Manager) and Staff 3 (Director of Regional Operations) on 11/28/22. Staff 1 and Staff 2 acknowledged the above areas needed to be cleaned and repaired.

Each cited item has been cleaned/corrected to correct the rule violation affecting all residents. Operations Leader reviewed the community's Food Handling Policy with all Food & Beverage team members. A Sanitation Inspection Form has been established for the community and will be completed by a different team member on a monthly basis. The monthly Sanitation Inspection form will be reviewed by the Chef, who will review the findings and any plans with the General Manager/designee at the weekly 1:1 GM/Chef meeting and documented using the established meeting agenda template. The General Manager is responsible to see that the corrections are completed and monitored.

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 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the Assisted Living kitchen with Staff 1 (General Manager) on 05/04/23 at 3:40 pm, revealed the following: * The kitchen entrance door frame had a chip in the plaster exposing the dry wall underneath and a golf ball sized hole on the frame;   * The wall directly behind the dish machine and sink beside the dish machine had splattered food, dust and dirt; * Baseboard directly behind the dish machine was cracked and broken; * Shelving in the walk-in refrigerator and freezer had a build-up of dirt and debris; * There was a broken stainless-steel drawer face that had dirt and debris on it; * The ice machine vents had accumulated dust on them; * The can opener holder had a build-up of food debris; * Lack of test strips to check sanitizers; * The dry food storage bins had dirt and food matter on their tops and sides; and * Shelving in the dry food storage had a build-up of dirt and debris. The surveyor reviewed the above areas needing cleaning and repair with Staff 1 (General Manager) on 05/04/23. Staff 1 acknowledged the above areas needed to be cleaned and repaired.

Operation Leader and General Manager have revied the Food Handling Policy with all members of the food and beverage team.   A Sanitation inspection form has been established. Chef will finalize all inspections weekly with the help of Sous Chef and Restaurant Supervisor, to ensure all aspects of the kitchen are clean and sanitized. The General Manager and the Chef will go over the weekly sanitation in their weekly meeting using the meeting template. General Manager as well as the kitchen management team will notify the plant operations supervisor of any repairs that need to be made in a timely manner. General manager and Plant operations supervisor will address any issues involving the kitchen in their weekly meeting using the meeting template. The General manager is responsible for ensuring that those responsible are being monitored and sanitation is being completed.

Based on observation 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.

Each cited item has been cleaned/corrected to correct the rule violation affecting all residents. Operations Leader reviewed the community's Food Handling Policy with all Food & Beverage team members. A Sanitation Inspection Form has been established for the community and will be completed by a different team member on a monthly basis. The monthly Sanitation Inspection form will be reviewed by the Chef, who will review the findings and any plans with the General Manager/designee at the weekly 1:1 GM/Chef meeting and documented using the established meeting agenda template. The General Manager is responsible to see that the corrections are completed and monitored.

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

Refer to C240

Based on observation and interview, 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 240.

refer to tag C240

The findings of the kitchen inspection, conducted 11/28/22 through 11/29/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 11/29/22, completed on 05/04/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the 11/29/22 kitchen inspection, conducted on 07/28/23, are documented in this report. It was determined the facility was in substantial compliance with 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.