Silver Creek Memory Care Community

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.

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

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

This Rule is not met as evidenced by:

Based on 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.

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

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

This Rule is not met as evidenced by:

Based on 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.

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

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

This Rule is not met as evidenced by:

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

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

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

This Rule is not met as evidenced by:

Based on 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.

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

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

This Rule is not met as evidenced by:

Based on observation, 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.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to 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.

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

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

This Rule is not met as evidenced by:

Based on 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.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

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

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

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

This Rule is not met as evidenced by:

Based on observation, 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.

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.

This Rule is not met as evidenced by:

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.

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.

This Rule is not met as evidenced by:

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).

This Rule is not met as evidenced by:

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.

This Rule is not met as evidenced by:

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.

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

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

This Rule is not met as evidenced by:

Based on 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.

This Rule is not met as evidenced by:

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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

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 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.