Silver Creek Memory Care Community

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 03/03/26 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: * Interior of ice maker – build up of black/pink matter; * Interior of microwave – food spills/splatters; * Fronts of doors and walls under prep counter next to bulk food bins near walk in refrigerator – spills/drips/splatters; * Ceiling vent above spice shelf – build up of dust; * Shelf above cooking equipment – spills/drips/greasy; and * Side of stove/grill – drips/spills/splatters. Other areas of concern included: * Garbage cans in food prep areas without lids when not in use; * Colored cutting boards – worn and scored; and * Eating utensils (knives/forks/spoons) were stored with handles down creating potential for cross contamination. The areas of concern were observed and discussed with Staff 1 (Director of Dining Services) on 03/03/26. The findings were acknowledged at 12:30 pm.

The following areas in observation of the kitchen have been addressed as described below: * Interior of ice maker – build up of black/pink matter; Area cleaned by 3/16/2026. * Interior of microwave – food spills/splatters; Area cleaned 3/3/2026. Ordered replacement will be in place by 4/1/2026. * Fronts of doors and walls under prep counter next to bulk food bins near walk in refrigerator – spills/drips/ splatters; Area cleaned by 3/16/2026. * Ceiling vent above spice shelf – build-up of dust; Area cleaned by 3/16/2026. * Shelf above cooking equipment – spills/drips/greasy; Area cleaned by 3/16/2026. * Side of stove/grill – drips/spills/splatters; Area cleaned by 4/1/2026. Other areas of concern included: * Garbage cans in food prep areas without lids when not in use; Ordered garbage can lids will be in place by 4/1/2026. * Colored cutting boards – worn and scored; Ordered cutting boards will be in place by 4/1/2026. * Eating utensils (knives/forks/spoons) were stored with handles down, creating potential for cross contamination; Area and all utensils washed/cleaned and stored with handles up by 3/6/2026. All areas above added to preventative daily, weekly, and monthly cleaning schedule. Weekly audits on all food outlets will be completed by Dining Services Director. Executive Director and Dining Services Director to conduct routine community kitchen inspections at least monthly to check for areas needing cleaned, repaired, or replaced.

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 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.

Refer to POC for 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.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable.

Based on observation, interview, and record review, it was determined the facility failed to ensure 2 of 2 sampled residents (#’s 2 and 4) were treated with dignity and respect during meal service. Findings include, but are not limited to: Observations were conducted of dining service on 09/09/25 and 09/10/25. The following concerns were identified: 1. Resident 2 moved into the facility in 11/2020 with diagnoses including degeneration of the brain, dysphagia, and a history of weight loss. The resident was observed to require cueing and physical feeding assistance and received a mechanical soft diet and pre-thickened nectar thick liquids. * Staff 10 (MT), Staff 11 (CG) and Staff 16 (CG) were observed standing while assisting and feeding Resident 2. The resident was seated in a wheelchair in the dining room, while staff remained standing while feeding the resident, rather than positioning at eye level or sitting beside the resident. * Staff 10, 11, and 16 were observed to lean over and/or into the resident and Resident 2 was noted to lean away from staff, appearing to avoid contact. * Residents were observed to receive vanilla ice cream for dessert at lunch, however Resident 2 was not provided dessert. On 09/10/25 at 12:19 pm, Staff 11 reported the resident didn’t like ice cream and was unsure if an alternate dessert was available. Staff 9 (MT) reported there were alternate dessert options, and she would ask what was available. However, Resident 2 was not provided an alternate dessert. The need to ensure residents were treated with dignity and respect was reviewed with Staff 1 (Memory Care Administrator), Staff 2 (Administrator), and Staff 3 (RN) on 09/11/25 at 3:37 pm. They acknowledged the findings. 2. Resident 4 moved into the facility on 08/2025 with diagnoses including dementia. * On 09/10/25, lunch served to residents was a tuna sandwich, cucumber/tomato salad, and potato chips. Resident 4 did not eat the tuna sandwich. Staff 11 was observed removing a dirty plate from Resident 4, but did not ask the resident why he/she did not eat or if he/she needed an alternative. * Surveyor interviewed Resident 4 to ask why he/she did not eat the tuna sandwich. The resident stated, “I didn’t know what it was, so I ate that (pointing at a potato chip bag) instead”. The need to ensure residents were treated with dignity and respect during meal service was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Administrator), and Staff 3 (RN) on 09/11/25 at 1:45 pm. They acknowledged the findings.

The facility failed to ensure 2 of 2 sampled residents (#’s 2 and 4) were treated with dignity and respect during meal service. *Staff will be provided training regarding assisting resident's with feeding so that they are treating resident's with dignity and respect. Staff training will also include explaining what is being served for meals, so if resident's don't like what is being served they can be offered an alternative off the alt menu. *Staff immediately made aware that the refridgerator in MC is stocked with alternate options for resident's with texture diet order's. *Staff training will be provided at all staff on 10/10/25. *New hire care partner skills checklists include assisting with eating. *Training will be reviewed bi-annually. *Administrator, MC Administrator, RCC and Business Services Director to oversee the compliance with QA audits to review documentation.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs;

Based on observation, interview, and record review, it was determined the facility failed to ensure a daily program of social and recreational activities that was based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to: During the survey, the memory care was home to 15 residents. The residents did not initiate any activities. Residents were observed wandering the unit and several residents spent time sitting in chairs near the staff charting area. From 09/08/25 through 09/11/25, observations were made, interviews were conducted, and the memory care activity calendar for September 2025 was reviewed. The following was revealed: The following scheduled activities were observed in the memory care: * 09/08/25 at 2:00 pm – “Root Beer Float Cart”; * 09/09/25 at 8:45 am – “Morning Meet”; and * 09/10/25 at 8:45 am – “Morning Meet”. During the survey, staff were observed to ask residents if they wanted to participate in an activity located in the assisted living, that included exercise, bingo, and music. On 09/11/25 at 11:06 am, Staff 2 (Administrator) confirmed the activities listed on the memory care activity calendar were not specific to the memory care. Therefore, the facility failed to ensure the memory care had a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs. The need to ensure a daily activity program was provided in the memory care for residents to address their mental, physical, and psychosocial needs was reviewed with Staff 1 (Memory Care Administrator), Staff 2, and Staff 3 (RN) on 09/11/25 at 3:37 pm. They acknowledged the findings.

The facility failed to ensure a daily program of social and recreational activities that was based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. *October activity calander was updated to reflect activities specific to the memory care based upon individual and group interests and physical, mental, and psychosocial needs of our resident's. *The activity calander is reviewed monthly before posting. *Administrator, MC Administrator, and Life Enrichment Director to oversee the compliance with monthly QA audits to review documentation.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs;

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 maintain effective infection prevention and control protocols for multiple sampled and unsampled residents related to dining services. Findings include, but are not limited to: Multiple meals were observed in the memory care unit between 09/09/25 and 09/11/25. a. Staff were observed serving meals and beverages, touching residents, touching their own faces, and scratching noses, picking up dirty plates, serving desserts, and assisting residents with feeding without changing gloves or performing hand hygiene between all clean and dirty tasks. b. Direct care staff were observed serving meals and providing feeding assistance to sampled and unsampled residents without donning a protective barrier over potentially contaminated clothing. c. A dietary staff member was observed delivering food to the unit without covering fruit bowls on 09/09/25, the side of the tomato/cucumber salad on 09/10/25, and the ice cream desserts on both days. Also, direct care staff were observed delivering an ice cream dessert to a resident in the room without covering. The need to ensure the facility maintained infection prevention and control protocols to provide a safe, sanitary, and comfortable environment during meal service was reviewed on 09/11/25 at 1:45 pm with Staff 1 (Memory Care Administrator), Staff 2 (Administrator), and Staff 3 (RN). They acknowledged the findings.

The facility failed to maintain effective infection prevention and control protocols for multiple sampled and unsampled residents related to dining services. *Staff provided hand washing training at all staff on 9/10/2025. Reviewed hand washing policy. *Dietary staff immediately educated on infection prevention and control protocols to provide a safe, sanitary environment. Reviewed the importance of covering food while its being transported or served to a resident's apartment. *New hire dining assistant skills checklists updated 10/1/25 to include hand washing and transporting food. *Training will be reviewed bi-annually. *Administrator, MC Administrator, Dining Services Director and Business Services Director to oversee the compliance with QA audits to review documentation.

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 3 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to: Resident 2 moved into the memory care community in 11/2020 with diagnoses including degeneration of the brain, dysphagia, and had a history of weight loss. The resident’s record, including current physician's orders and MAR/TAR, dated 08/01/25 through 09/08/25, were reviewed. The following was identified: Resident 2 had a physician's order for a health shake to be offered twice daily at 10:00 am and 3:00 pm. The resident’s record noted the health shake was not administered as ordered on 43 occasions. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Memory Care Administrator), Staff 2 (Administrator), and Staff 3 (RN) on 09/11/25 at 3:37 pm. They acknowledged the findings.

The facility failed to ensure physician orders were carried out as prescribed for 1 of 3 sampled residents (#2) whose orders were reviewed. *Community RN immediately updated the health shake instructions to ensure physician orders are carried out as prescribed. New instructions as follows; Please offer nectar thick health shake twice a day (one between breakfast and lunch and the second one between lunch and dinner) document percentage of health shake drank. If resident is sleeping, please reattempt to offer health shake when she wakes up. Thickened health shakes are provided by conservator. Please contact conservator and the health services team when she is down to one week of health shakes left. *QA audit will be completed weekly to review missed doses. *RN, administrator, MC administaror, and RCC to oversee the compliance with QA audits to review documentation.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean. Findings include, but are not limited to: The facility was toured throughout the survey, 09/08/25 to 09/11/25, and the following was identified: Interior cleaning was needed in the following areas: * Gray carpet throughout the facility had black and brown stains and debris in multiple areas; and * Gray chairs across from the staff charting area had brown stains in multiple areas. During a facility tour on 09/11/25 at 4:45 pm, the need to ensure the interior of the facility was kept clean was discussed with Staff 1 (Memory Care Administrator). She acknowledged the findings.

The facility failed to ensure all interior materials and surfaces were kept clean. *Community is on a carpet cleaning schedule with Summit. Carpets were re cleaned on 9/12/25 and will be cleaned every other month and as needed. *ESD and housekeepers spot clean carpets and fabric chairs as needed. *QA audits will be completed weekly to review carpet and furniture to ensure the interior of the facility is kept clean. *ESD, Administrator, and MC Administrator to oversee the compliance with QA audits to review documentation.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

Based on observation, interview, and record review, it was determined the facility failed to ensure 2 of 2 sampled residents (#’s 2 and 4) were treated with dignity and respect related to meal service. Findings include, but are not limited to: Refer to C200.

Refer to C200.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

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 and interview, it was determined the facility failed to provide each individual privacy in his or her own unit for multiple sampled and unsampled residents who resided in shared units. Findings include, but are not limited to: During the acuity interview on 09/08/25, the survey team was provided with a resident roster which indicated there were three double occupancy rooms in the facility. Each of the double occupancy rooms had two residents sharing one unit. The semi-private rooms that were shared between two residents had no means to provide privacy for one of the two residents when someone entered or exited either of the bedroom areas or when ADL cares were provided outside of the bathroom. The need to ensure residents’ right to be afforded privacy within their own unit was discussed with Staff 1 (Memory Care Administrator) on 09/11/25 at 2:30 pm. She acknowledged the findings.

The facility failed to provide each individual privacy in his or her own unit for multiple sampled and unsampled residents who resided in shared units. *Community will install privacy curtains between each shared semi-private room to ensure residents’ right to be afforded privacy within their own unit. These will be installed by 11/10/2025. *Staff training will be provided by 11/10/2025 to ensure staff know how and when to use the privacy curtain to to ensure residents’ right to be afforded privacy within their own unit. *Instructions will also be added to each resident's growth and wellness plan by 11/10/2025. *ESD, Administrator, and MC Administrator to oversee the compliance.

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.

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 limited to: Refer to C200, C242, C295, and C513.

Refer to C200, C242, C295, and C513.

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

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: C303.

Refer to: C303.

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 observation, interview, and record review, it was determined the facility failed to ensure a daily meal program for nutrition and hydration was provided based upon the resident’s preferences and needs for 1 of 3 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 11/2020 with diagnoses including degeneration of the brain, dysphagia, and had a history of weight loss. During the survey Resident 2 was observed to require assistance with eating and drinking and could not initiate requests for food or fluids. The resident received a mechanical soft diet and nectar thick liquids. Resident 2’s service plan, dated 09/08/25, and “[Individualized] Hydration and Nutrition Plan”, dated 06/29/25, were reviewed. Observations were made and interviews with staff were conducted. The following was identified: Resident 2’s record noted the resident liked “…just about everything”, however on 09/09/25 and 09/10/25, during meal observations, Resident 2 did not eat the provided side dishes, consisting of cottage cheese and apple sauce, and did not receive ice cream for dessert. On 09/10/25 at 11:47 am, Staff 6 (CG) reported Resident 2 didn’t like apple sauce and would “sometimes” eat cottage cheese. Staff 6 additionally reported the resident preferred to eat one food at a time. On 09/10/25 at 12:19 pm, Staff 11 (CG) reported “[Resident 2] doesn’t like ice cream...it’s too cold.” The resident’s record noted for staff to “…offer/encourage/assist [Resident 2] with snacks [and] fluids between meals.” However, throughout survey there were no observations of staff offering, encouraging, or assisting Resident 2 with snacks or fluids in-between meals. The resident’s nutrition and hydration plan was not reflective of the resident’s current needs and preferences, and lacked individualized instruction related to resident preferences, snacks, and hydration. The need to ensure an individualized nutrition and hydration plan that was based on the resident’s preferences and needs was developed was reviewed with Staff 1 (Memory Care Administrator), Staff 2 (Administrator), and Staff 3 (RN) on 09/11/25 at 3:37 pm. They acknowledged the findings.

The facility failed to ensure a daily meal program for nutrition and hydration was provided based upon the resident’s preferences and needs for 1 of 3 sampled residents (#2) whose service plans were reviewed. *Resident's individualized nutrition and hydration plan will be updated by 11/1/2025 and will be reviewed quarterly. *Staff immediately made aware that the refridgerator in MC is stocked with alternate snack options for resident's with texture diet order's, as well as thickened liquids. *DSD, Administrator, MC Administrator, and RCC to oversee the compliance with QA audits to review documentation.

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 ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to: Residents 1, 2 and 3’s current service plans, dated 08/14/25, 09/08/25, and 08/13/25, respectively, and “Getting to Know You” questionnaires were reviewed. There was no documented evidence the facility had evaluated and developed individualized plans based on each residents': * Past and current interest; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; and * Adaptations necessary for the resident to participate. The need to ensure each resident was evaluated for activities and an individualized activity plan was developed was discussed with Staff 1 (Memory Care Administrator) on 09/11/25. She acknowledged the findings.

The facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. *Each of the sampled resident's individualized activity plans will be developed and implemeted by 11/1/2025 and will be reviewed quarterly. *Life Enrichment Director, Administrator, MC Administrator re educated on fully completed and updated Getting to Know You Forms to to ensure each resident was evaluated for activities and an individualized activity plan was developed. *Life Enrichment Director, Administrator, MC Administrator, and RCC to oversee the compliance with QA audits to review documentation.

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 and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner and ensure food was prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). Findings include, but are not limited to: On 08/19/25, from 9:53 am to 2:12 pm, interviews with staff and observations of the facility kitchen, memory care kitchenette, food storage areas, food preparation, and food service were conducted. The following was identified: a. The flooring in the kitchen was noted in need of repair and had cracks and breaks and large areas where the transition seal, between flooring material, was missing, worn, or peeling. At 12:08 pm, Staff 3 (Maintenance Director) reported the flooring had been worked on and resealed in the past and acknowledged the areas reviewed needed repair. b. The facility lacked the proper testing strips required to ensure proper sanitization was completed throughout the kitchen, including food contact and non-food contact surfaces and staff were unaware how to use test strips to check sanitizers. On 08/19/25 at 12:16 pm, Staff 2 (Dining Service Director) toured the kitchen with this surveyor and reviewed the above. The need to ensure the kitchen was maintained in a sanitary manner and food was prepared and served in accordance with Food Sanitation Rules was reviewed with Staff 1 (Administrator) and Staff 2 on 08/19/25 at 12:51 pm. They acknowledged the findings.

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 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.

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 411-054-0030 (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 09/11/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: * Equipment/kitchen areas with significant accumulation of dust: - Ceiling vents throughout the kitchen; - Ceiling light covers and ceiling area surround lights; - Ceiling sprinkler heads; - Fire extinguisher stored next to food prep area; and - Walk in refrigerator ceiling above door;. *Equipment with buildup of spills/splatters/drips/grease/debris/smears and/or black matter: - Top, sides and underneath the dishwashing machine; - Garbage disposal in dishwashing area; - Wall behind and underneath dishwashing machine; - Floor under and behind dishwashing machine; - Stainless steel refrigerator doors; - Commercial mixer food guard; - Lids of food storage bins; - Stainless steel cabinet doors in prep area and cabinet wall siding where food bins stored; - Sides, knobs, oven doors and wall behind stove/grill; - Hood vents above stove/grill; - Wall behind and below counter where toaster is stored; - Shelves above and below steam table; - Knobs on the steam table; and - Interior of ice machine. * Colored cutting boards had significant gouges causing the boards to be “white” with finish worn off, creating potential uncleanable surfaces and risk of cross contamination. The areas of concern were observed and discussed with Staff 1 (Dining Services Director) and discussed with Staff 2 (ALF Administrator) and Staff 3 (MCC Administrator) on 09/11/24. The findings were acknowledged.

The following areas in observation of the kitchen have been addressed as described below: 1.Equipment/kitchen areas with significant accumulation of dust: - Ceiling vents throughout the kitchen; Areas cleaned by 10/20/2024 - Ceiling light covers and ceiling area surround lights; Areas cleaned by 10/20/2024 - Ceiling sprinkler heads; Areas cleaned by 10/15/2024 - Fire extinguisher stored next to food prep area; and Area cleaned by 10/15/2024 - Walk in refrigerator ceiling above door. Area cleaned by 10/15/2024 2.Equipment with buildup of spills/splatters/drips/grease/debris/smears and/or black matter: - Top, sides and underneath the dishwashing machine; Areas cleaned by 10/20/2024 - Garbage disposal in dishwashing area; Area cleaned by 10/20/2024 - Wall behind and underneath dishwashing machine; Areas cleaned by 10/20/2024 - Floor under and behind dishwashing machine; Areas cleaned by 10/20/2024 - Stainless steel refrigerator doors; Area cleaned by 10/15/2024 - Commercial mixer food guard; Area cleaned by 10/15/2024 - Lids of food storage bins; Areas cleaned by 10/15/2024 - Stainless steel cabinet doors in prep area and cabinet wall siding where food bins were stored; Areas cleaned by 10/20/2024 - Sides, knobs, oven doors and wall behind stove/grill; Areas cleaned by 10/20/2024 - Hood vents above stove/grill; Areas cleaned by 10/20/2024 - Wall behind and below counter where toaster was stored; Areas cleaned by 10/20/2024 - Shelves above and below steam table; Areas cleaned by 10/20/2024 - Knobs on the steam table; and Areas cleaned by 10/20/2024 - Interior of ice machine. Area cleaned by 10/15/2024 3. Colored cutting boards had significant gouges causing the boards to be “white” with finish worn off, creating potential uncleanable surfaces and risk of cross contamination. Ordered cutting boards will be in place by 10/20/2024. All areas above added to preventative daily, weekly, and monthly cleaning schedule. Weekly audits on all food outlets will be completed by Dining Services Director. Administrator and Dining Services Director to conduct routine community kitchen inspections at least monthly to check for areas needing cleaned, repaired, or replaced.

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 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.

Refer to POC for C240

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

Based on interview and record review, conducted during a site visit on 12/07/23, it was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but are not limited to: During an interview on 12/07/23, Staff 1 (ED) and Staff 2 (MCC Administrator) explained the tool the facility used was SPA. Staff 1 stated residents received points for ADLs, those points were converted into minutes. To get the staffing numbers, s/he takes the total minutes and divide that by 60 (60 minutes in an hour), then divide that total number by 7.5 (amount of working hours in a shift) and that gave the number of staff needed for the building per day. Staff 1 was unable to explain how the tool determined individual staffing numbers for each shift. Staff 1 was unable to tell the CS how the point level was determined for ADLs and how that converted into minutes. A review of the facility's ABST, on 12/07/23, indicated the following: ·A total of 3482.5 minutes of care and required 7.73 care staff needed per day. ·The tool addressed 17 of the required 22 ADLs. The missing ADLs included: oAssisting with communication, assistive devices for hearing, vision, and speech. oResponding to call lights. oSafety checks, fall prevention. oCompleting resident specific housekeeping or laundry services performed by care staff. oProviding additional care services, such as smoking or pet care. A review of the facility's posted staffing plan indicated on day and swing shift the facility scheduled one MT, two CG, and on NOC shift there is one MT and one CG. The facility failed to update an acuity-based staffing tool that addressed all the 22 activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care and, as a result, the facility's acuity-based staffing tool does not reflect the correct care time for each resident. On 12/07/23, the findings were reviewed with and acknowledged by Staff 1 and Staff 2.

The findings of the on-site investigation, conducted on 12/07/2023, 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 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:   1. Observation of the kitchen on 08/22/22 revealed an accumulation of food spills, splatters, loose food debris, dirt and/or dust on or underneath the following:   * Dry food storage area; * Hand washing sinks and towel dispensers; * Surfaces and underneath storage shelves, cabinets, and drawers throughout the kitchen; * The coffee and beverage countertop inside the kitchen; * Walls throughout the kitchen; * Floors and drains; * Flooring inside the walk-in refrigerator and freezer; * The dishwashing area walls, floors, and equipment; * Behind and underneath appliances; * Food delivery carts; * Ceiling vents; * Interior of the microwave; * Ice machine vent had a buildup of dust; * Janitor closet inside the kitchen area needed to be deep cleaned, sanitized, and properly organized; * Doors and door frames throughout the kitchen had chipped paint, scuffs, gouges, and food stains; * Food was stored on the floor of the freezer; * Opened and leftover food items that were stored in the refrigerator were not consistently dated; * Opened food items were observed in the dry food storage area; and * Garbage cans in food preparation areas did not have lids when not in use.   2. The kitchenette in the MCC was toured on 08/23/22. The following areas were in need of cleaning and/or repair:   * Laminate countertop had chips in multiple areas, and edge of countertop next to the steam table was missing laminate; * Cabinets under the kitchenette sink were chipped and splintered on the corners; * The steam table had food debris in the water and brown markings in the wells; * The drain underneath the steam table had thick black and brown matter; and * Caregiving staff plating and serving food were not using aprons.   The areas that required cleaning and repair were observed and discussed with Staff 1 (ED) and Staff 5 (Executive Chef) on 08/24/22. They acknowledged the areas that needed cleaning and repair.

The following areas in  observation of the kitchen have been addressed as described below: 1. Accumulation of food spills, splatters, loose food  debris, dirt and/or dust on or underneath the following: *Dry food storage area; Area cleaned by 10/1/2022. *Hand washing sinks and towel dispensers; Sinks and towel dispensers cleaned by 10/1/2022 *Surfaces and underneath storage shelves, cabinets, and drawers throughout the kitchen; Areas deep cleaned by 10/1/2022 *The coffee and beverage countertop inside the kitchen; Area cleaned by 10/1/2022. *Walls throughout the kitchen; Areas cleaned by 10/1/2022. *Floors and drains; Areas cleaned by 10/1/2022. *Flooring inside the walk-in refridgerator and freezer; Flooring deep cleaned by 10/22/2022. *The dishwashing area walls, floors, and equipment; Dishwashing area deep cleaned by 10/22/2022. * Behind and underneath appliances; Areas cleaned by 10/1/2022 * Food delivery carts; Carts cleaned by 10/1/2022. * Ceiling vents; Vents cleaned by 10/22/2022. * Interior of the microwave; Microwave cleaned by 10/1/2022. * Ice machine vent had a buildup of dust; Area cleaned by 10/1/2022. * Janitor closet inside the kitchen area needed to be deep cleaned, sanitized, and properly organized; Janitor closet will be deep cleaned, sanitized, and properly organized by 10/22/2022. * Doors and door frames throughout the kitchen had chipped paint, scuffs, gouges, and food stains; Doors and door frames throughout the kitchen cleaned, repaired, and repainted as needed by 10/22/2022 * Food was stored on the floor of the freezer; Ordered storage bins will be in place by 10/1/2022. * Opened and leftover food items that were stored in the refrigerator were not consistently dated; Opened and leftover food items will dated by 10/1/2022 * Opened food items were observed in the dry food storage area; Ordered storage bins will be in place by 10/1/2022. * Garbage cans in food preparation areas did not have lids when not in use Ordered garbage can lids will be in place by 10/1/2022 All areas above added to preventative daily zone deep cleaning schedule. Weekly audits on all food outlets will be completed by Executive Chef. ED and Executive Chef to conduct routine community kitchen inspections  at least monthly to check for areas needing cleaned, repaired, or replaced. 2. The kitchenette in the MCC; the following areas were in need of cleaning and/or repair: * Laminate countertop had chips in multiple areas, and edge of countertop next to the steam table was missing laminate; Laminate countertop unrepairable so it will be replaced by 10/22/2022. * Cabinets under the kitchenette sink were chipped and splintered on thecorners; Cabinets unrepairable so it will be replaced by 10/22/2022.   * The steam table had food debris in the water and brown markings in the wells; Steam table deep cleaned by 10/1/2022 * The drain underneath the steam table had thick black and brown matter; Drain deep cleaned by 10/22/2022 * Caregiving staff plating and serving food were not using aprons. Disposable aprons ordered and in place by 10/1/2022. All areas above added to preventative daily zone deep cleaning schedule. Weekly audits on all food outlets will be completed by Executive Chef. ED and Executive Chef to conduct routine community kitchen inspections  at least monthly to check for areas needing cleaned, repaired, or replaced.

Based on interview and record review, it was determined the facility failed to ensure evaluations were reviewed and updated quarterly and after significant changes of condition for 1 of 2 sampled residents (# 1). Findings include, but are not limited to: Residents 1's evaluations were not completed quarterly as required. Additionally, Resident 1 experienced several significant changes of condition  between June and August, 2022. There was no documented evidence the previous evaluation had been reviewed and updated. The need to ensure resident evaluations were reviewed and updated at least quarterly and with significant changes of condition was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. The staff acknowledged the findings.

Residents 1's evaluations were not completed quarterly as required. Additionally, Resident 1 experienced several significant changes of condition between June and August, 2022. There was no documented evidence the previous evaluation had been reviewed, updated, and did not contain items listed in citation. Resident 1 will have review of service plan and update to reflect current care needs (Sleeping area preference; Two person full assist with care; Bed mobility; Transfers; Dressing; Grooming; Hygiene; Bathing; Bowel and bladder continence; Rash; Meal assistance; Orientation; Ability to use call system; Psychotropic medications; Expressions of pain; Hospice Services; Ability to make self understood; Significant weight losses; and Risk for dehydration) and completed by 9/1/2022.All resident's service plans will be reviewed, with ISP or handwritten changes that are initial and dated implemented for any care needs not addressed in service plan by 10/22/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change of condition). ED, HSD, and MCD will be re-educated on completed timely and comprehensive evaluations by VPO or Nurse Consultant by 10/1/2022. Random SP audits to be conducted by Health Services Department during QA process at least monthly. Staff to be educated on reporting changes of condition to HSD and documenting on 24-hour report that will be reviewed daily by Health Services Department. Weekly audit of Service Plan binder to ensure most accurate SP is available to staff.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, updated with changes, 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 05/2022 with diagnoses including dementia and depression. Observations, interviews and review of the current service plan, dated 08/03/22, indicated the service plan failed to reflect the resident's current care needs and lacked clear direction to staff in the following areas: * Recent hospital stay for a subarachnoid hemorrhage; * Falls and interventions; * Recent injuries sustained from falls; * Toileting assistance during the night; and * Ability to use the call system. The need to ensure service plans were reflective of residents' current needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22 . They acknowledged the findings. 2. Resident 1 was admitted to the facility in May 2019 with diagnoses including dementia and was receiving hospice services since 03/2022. Observations of the resident, interviews with staff and review of the care plan dated 10/18/21, showed the care plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Sleeping area preference; * Two person full assist with care; * Bed mobility; * Transfers; * Dressing; * Grooming; * Hygiene; * Bathing; * Bowel and bladder continence; * Rash; * Meal assistance; * Orientation; * Ability to use call system; * Psychotropic medications; * Expressions of pain; * Hospice Services; * Ability to make self understood; * Significant weight losses; and * Risk for dehydration.   The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 3 (RN) on 08/23/22 and Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 on 08/24/22. They acknowledged the findings.

1. Resident 2 Observations, interviews and review of the current service plan, indicated the service plan failed to reflect the resident's current care needs, lacked clear direction to staff and did not contain items listed in citation. Resident 2 will have review of service plan and update to reflect current care needs (Recent hospital stay for a subarachnoid hemorrhage; Falls and interventions; Recent injuries sustained from falls; Toileting assistance during the night; and Ability to use the call system) and completed by 9/15/2022. 2. Resident 1 Observations of the resident, interviews with staff and review of the care plan, showed the care plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and did not contain items listed in citation. Resident 1 will have review of service plan and update to reflect current care needs (Sleeping area preference; Two person full assist with care; Bed mobility; Transfers; Dressing; Grooming; Hygiene; Bathing; Bowel and bladder continence; Rash; Meal assistance; Orientation; Ability to use call system; Psychotropic medications; Expressions of pain; Hospice Services; Ability to make self understood; Significant weight losses; and Risk for dehydration) and completed by 9/1/2022. All resident's service plans will be reviewed, with ISP or handwritten changes that are initial and dated implemented for any care needs not addressed in service plan by 10/22/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change of condition). ED, HSD, and MCD will be re-educated on completed timely and comprehensive service plans by VPO or Nurse Consultant by 10/1/2022. Staff to be educated on utilization of service plans for providing care by 10/1/2022. ED and/or HSD to review service plans prior to locking to ensure they reflect the Resident current care needs on an ongoing basis. Random SP audits to be conducted by Health Services Department during QA process at least monthly.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team which included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: The most recent service plans for Residents 1 and 2 were reviewed during the survey. The records lacked documented evidence the service plans were developed by a service planning team. On 08/24/22, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN). They acknowledged the findings.

Resident 1 & 2 will have service plans reviewed by Service Plan Team that will consist of the following members at a minimum: Executive Director, Health Services Director, Memory Care Director, Lifestyle Director, Resident/Responsible Party will be invited to attend and participate as part of this team. Other team member will be included on a Resident-by-Resident basis to include: Caseworker, Hospice, and other Third-Party Providers as appropriate. Executive Director and/or HSD will oversee compliance by reviewing Service Plans prior to locking.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific interventions were developed, and that interventions were re-evaluated to determine effectiveness for 1 of 1 sampled resident (#2) who experienced changes of condition related to multiple falls. Findings include, but are not limited to: Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the service plan dated 08/03/22, temporary service plans, incident investigations and charting notes dated 05/27/22 through 08/24/22 were reviewed. Resident 2 experienced ten falls, some with injuries, between 05/29/22 and 08/22/22. The facility failed to complete investigations at the time of incident and determine if service-planned interventions were implemented, were effective or if new interventions were needed following each fall. The need to ensure fall investigations were completed timely, and interventions were reviewed to determine if they were effective and appropriate was shared with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. They acknowledged the findings.

The community acknowledged incomplete investigations at the time of incident and determine if service-planned interventions were implemented, were effective or if new interventions were needed following each fall. The health services department reviews high risk residents weekly, documentation will be updated to reflect if current interventions are effective and appropriate. ED, HSD, and MCD will be re-educated on completed timely fall investigations and incident reports by VPO or Nurse Consultant by 10/1/2022.

Based on observation, interview and record review, it was determined the facility failed to ensure RN significant change of condition assessments, including findings, resident status, and interventions made as a result of the assessments, were completed following severe, weight loss and decline in condition for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: Resident 1 was admitted to the facility in May 2019 with diagnoses including dementia. a. The resident was observed during survey to be bed bound and required full assist with all cares. Review of the resident's record revealed an RN assessment had been completed on March 31, 2022, after Resident 1 was admitted to hospice services for dementia,   with fluctuating weights and ongoing meal refusals, and noted continued weight loss was expected. The resident was started on protein shakes three times a day. Documentation showed refusal of meals continued, although Resident 1 continued to accept the protein drinks provided. Staff interviewed during survey, reported Resident 1 had a decline in condition in June 2022, going from independent in mobility and all ADLs, to needing full assist from staff. There was no RN assessment of the significant change of condition, nor was the service plan updated to reflect the resident's changes in care needs. Observations of care and staff interviewed during survey found that the staff knew how to care for the resident, and s/he was observed to be receiving the level of care indicated. b. A review of the resident's 05/05/22 through 08/22/22 progress notes, 03/2022 through 08/02/22 weight records, physician communications, and 08/01/22 through 08/22/22 MAR identified the following: * Resident continued to drink 50% to 75% of the protein shakes provided. * From 06/02/2022 to 07/02/22, Resident 1 lost 20 pounds, from 163.3 pounds to 143.3 pounds, a decrease of 13.9% of his/her total body weight. This constituted a severe weight loss. * Between 07/02/22 and 08/02/22, the resident lost an additional 6.4 pounds, from 143.3 pounds to 136.9 pounds. This constituted another severe loss in one month, and combined weight loss of 19.2% of his/her total body weight in two months. The resident was unable to be weighed during the time of the survey due to his/her further declines of condition. There was no documented RN significant change of condition assessment of the resident's severe weight losses, including findings, resident status, and interventions made as a result of the assessment. Staff 3 (RN) reported on 08/23/22 that he was aware of the resident's declining condition and weight loss, but did not complete an RN assessment, as the declines were expected. The need for significant change of condition assessments, which included findings, resident status, and interventions made as a result of the assessment, to be completed by an RN was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. They acknowledged the findings. The RN completed a change of condition assessment and the service plan was updated to reflect the resident's current care and services indicated on 08/22/22.

Resident 1 The community acknowledged there was no documented RN significant change of condition assessment of the resident's severe weight losses, including findings, resident status, and interventions made as a result of the assessment. Resident 1 The RN completed a change of condition assessment and the service plan was updated to reflect the resident's current care and services indicated on 08/22/22. The health services department reviews high risk residents weekly, hospice residents will be added to this weekly meeting to discuss current health status. ED, HSD, and MCD will be re-educated on the need for a change of condition assessment by VPO or Nurse Consultant by 10/1/2022.   Staff to be educated on reporting changes of condition to HSD and documenting on 24-hour report that will be reviewed daily by Health Services Department.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters for PRN medications for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in May 2019 with diagnoses including dementia, anxiety and agitated depression. Resident 1 was receiving hospice services. Review of the resident's 08/01/22 through 08/22/22 MAR and 07/25/22 physician orders were reviewed and showed the following: * The MAR included orders for PRN Morphine Sulfate to be administered every two hours as needed for pain or shortness of breath, and Lorazepam every four hours as needed for anxiety and agitation.  The nurse instructions for administration directed staff to administer the Morphine first to rule out pain as a source of anxiety. Lorazepam was to be given if the morphine was not effective after 30 minutes. On four occasions between 08/01/22 and 08/22/22 the Lorazepam was administered first, instead of the Morphine, and on one occasion both medications were administered at the same time. * The MAR included multiple PRN psychotropic medications for  anxiety, agitation, delirium and "behaviors".  The MAR did not contain resident specific instructions for staff describing how the resident expressed anxiety, agitation, delirium and "behaviors". The need to ensure MARs were accurate, included resident specific instructions, and the instructions were followed was discussed on 08/24/22 with Staff 1 (ED ), Staff 2 (Memory Care Administrator) and Staff 3 (RN). The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia and hypertension. Review of the resident's 08/01/22 through 08/22/22 MAR identified the following: * Multiple PRN bowel care medications lacked specific parameters and instructions to staff regarding administration. The need to ensure PRN medications included resident specific parameters and instructions for staff was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. They acknowledged the findings.

Resident 1 & 2 MAR will be updated to ensure PRN medications included resident specific parameters and instructions for staff prior to administartion of PRN medication. All residents PRN medications will be reviewed to ensure their MAR reflects resident specific parameters and instructions for staff prior to administartion by 10/22/2022. Med Techs will be re-educated on PRN medications; the need to ensure MARs are accurate, resident specific parameters and instructions, that the MAR is followed and documentation. HSD/Memory Care Director to oversee the compliance with MAR accuracy and documentation. HSD or Designee to oversee compliance with QMAR audits quarterly.

Based on observation, interview and record review, it was determined the facility failed to ensure a thorough assessment had been completed by an RN, PT or OT, and caregivers had been instructed on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (# 1) who used siderails. Findings include, but are not limited to: Resident 1 was admitted to the facility in May 2019 with diagnoses including dementia. Observations on 08/22/22 revealed two quarter length side rails in the up position on the resident's bed. Staff interviewed during survey reported the side rails had been on the bed for a few weeks. There was no RN, PT or OT assessment for use of the side rails including: *The resident specifically requested or approved of the device; *The facility had informed the individual of the risks and benefits associated with the device; * The facility had documented other less restrictive alternatives evaluated prior to the use of the device; and *Instructed caregivers on the correct use and precautions related to use of the device. The need to complete all required elements related to use of an assistive device with restraining qualities was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. They acknowledged the findings.

Community acknowledges incomplete required elements related to use of an assistive device with restraining qualities for Resident 1 and there was no RN, PT or OT assessment completed. The RN completed a change of condition assessment and the service plan was updated to reflect the resident's current care and services indicated on 08/22/22, which included the use of an assistive device with restraining qualities. ED, HSD, and MCD will be re-educated on all required elements related to use of an assistive device with restraining qualities by VPO or Nurse Consultant by 10/1/2022. Health Services Team will complete monthly audit for QA purposes on all residents that utilize assistive devices with restraining qualities to ensure all required elements are in place and the resident is still needing and able to use the device appropriately.   High Risk Board in HSD office will now list residents that use Supportive Devices with restraining qualities

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 February 2022 through July 2022 were reviewed with Staff 1 (ED) on 08/24/22 . Staff 1 revealed the facility did not relocate or evacuate the residents during their monthly fire drills. Therefore, documented evidence 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 provide evacuation assistance to residents from the building to a designated "point of safety" during fire drills was discussed with Staff 1 on 08/24/22. She acknowledged the findings .

Community acknowledged fire and life safety records were lacking documentation 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 provide evacuation assistance to residents from the building to a designated "point of safety" during fire drills. ED and ESD re-educated on fully completed fire drill logs and all required information by VPO by 10/1/2022 ED and ESD to oversee the compliance with fire and life safety with monthly QA audits to review documentation. Fire drill log document will be updated to list residents that participated in drill.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240 and C 420.

Refer to POC for C 240 and C 420

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 7 and 13) completed all required pre-service orientation prior to performing any job duties and 1 of 2 newly hired staff (# 13) 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 08/23/22 with Staff 1 (ED). 1. There was no documented evidence Staff 7 (CG), hired 07/01/22, and Staff 13 (CG), hired 02/17/22 had completed the required pre-service orientation topic related to Infectious Disease Prevention prior to performing any job duties. 2. There was no documented evidence Staff 13 (CG), hired 02/17/22 demonstrated competency in all assigned job duties within 30 days of hire in the following areas: * Providing assistance with ADLs; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. The need to ensure staff completed all required training within the specified time frames was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. They acknowledged the findings .

Community acknowledges incomplete staff training records for 2 of 2 newly hired staff. 1. There was no documented evidence Staff 7 (CG), hired 07/01/22, and Staff 13 (CG), hired 02/17/22 had completed the required pre-service orientation topic related to Infectious Disease Prevention prior to performing any job duties. The  pre-service infection prevention and control for community-based care will be completed by 10/1/2022. 2. There was no documented evidence Staff 13 (CG), hired 02/17/22 demonstrated competency in all assigned job duties within 30 days of hire in the following areas: * Providing assistance with ADLs; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. Skills checklist was completed and provided prior to survey exit on 8/24/2022. Monthly Sample of 5-10% employee records will be audited by BOM for QA purposes. All re-education and missing staff training records to be completed by 10/15/2022.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities.  Findings include, but are not limited to: Refer to C 252, C 260, C 262, C 270, C 280, C 310 and C 340.

Refer to POC C 252, C 260, C 262, C 270, C 280, C 310, and C 340

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 2 of 2 sampled residents (#s 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. During the survey, it was observed that snacks and hydration were not consistently offered to residents throughout the day. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN) on 08/24/22. They acknowledged the findings.

Resident 1 & 2 will have service plans updated to reflect hydration needs. Resident with specialized hydration needs will have service plans reviewed, with ISP or handwritten changes that are initial and dated implemented for any hydration needs not addressed in service plan by 10/22/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change in condition). Staff to be educated on hydration and inclusionof specialized hydration needs in service plans by 10/15/2022. ED and/or HSD to review service plans prior to locking to ensure they reflect the Specialized Hydration needs (as needed) on an ongoing basis. Random SP audits to be conducted by Health Service Department during QA process at least monthly.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation and failed to consistently provide meaningful activities for all residents that promoted or helped sustain physical and emotional well-being, for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Residents 1 and 2's service plans offered some information about the residents' historical and current interests, however, the facility had not fully evaluated the residents': * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There were no specific activity plans developed from the evaluations that detailed what, when, how and how often staff should offer and assist the resident with individualized activities. Observations and interviews indicated the residents were dependent on staff to initiate activities and scheduled activities were not consistently offered. On 08/24/22, the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plans for each resident was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN). They acknowledged the findings.

Resident #1 & #2 will have service plans updated to reflect individualized activity plans. Residents will have the following areas evaluated with each comprehensive evaluation: 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. Individulaized Activity Plans to be developed in the Service Plan for each resident. Current residents will be reviewed and an ISP or handwritten changes that are initial and dated implemented for individualized activity plans not addressed in service plan by 10/22/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change in condition). Staff to be educated on individualized activity plans and utilization of these plans by 10/15/2022. ED and/or HSD to review service plans prior to locking to ensure they reflect the individualized activity plan on an ongoing basis. Random SP audits to be conducted by Lifestyles Director for QA process at least monthly.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 1 sampled resident (# 1) with documented behaviors. Findings include, but are not limited to: Resident 1 was admitted to the facility in May 2019 with diagnoses including dementia, anxiety and agitated depression. Resident 1's August MAR revealed multiple psychotropic medications both scheduled and as needed for agitation, anxiety, delirium and delusions. The MAR did not include descriptions of how the resident would exhibit the behaviors. Staff interviewed during survey reported the resident would yell out, start "sobbing" for unknown reasons, shake and at times refused medication and cares. The resident's service plan, dated 10/18/21, did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 08/24/22 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (RN). The staff acknowledged the findings.

Resident 1 Service Plan will be updated to reflect behaviors to include the resident yelling out, start "sobbing" for unknown reasons, shake, at times refused medication and cares and indiviualized interventions to minimize or mitigate the potiential negative outcome from these behaviors by 9/15/2022. Other Residents with known behaviors will have service plans reviewed and updated as needed to reflect behaviors and individualized interventions to minimize or mitigate the potential negative outcome from these behaviors by 10/22/2022. ED and.or HSD to review service plans prior to locking to ensure they reflect the individualized intervention for behaviors on an ongoing basis. Random SP audits to be conducted by Health Services Team for QA process at least monthly.

The findings of the re-licensure survey, conducted 08/22/22 through 08/24/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily 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 revisit to the re-licensure survey of 08/24/22, conducted 12/07/22 through 12/08/22, 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.