Brookdale Geary Street Memory Care

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

Based on interview and record review, it was?determined?the facility?failed to?notify the physician or other practitioner when a resident refused to consent to orders for 1 of 1?sampled?resident (5) who?had repeated medication?refusals. Findings include, but are not limited to:? Resident 5 moved into the Memory Care Community in 02/2026 with diagnoses?including Parkinson’s disease and dementia. The resident's 02/04/26 through 03/16/26 MARs and physician orders were reviewed.? Staff documented the resident refused carbidopa/levodopa on nine occasions and entacapone on eight occasions,?both?medications?prescribed to manage symptoms of?Parkinson’s disease. There was no documented evidence that the facility notified the resident’s physician of?the repeated medication?refusals as?required.?? During an interview on 03/18/26 at 10:45 am, Staff 2 (RN) confirmed she was unable?to?locate?documentation showing the physician?had been notified.? The need to notify the?physician/practitioner when a resident refused to consent to orders was discussed with Staff 1 (ED),?Staff 2, and Staff?15?(RN/MSW) at 3:30?pm on 03/19/26. They acknowledged the findings.? ??

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

Based on interview and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan and failed to ensure established care time was resident specific rather than a predetermined average for 5 of 5 sampled residents (#s 1,2, 3, 4, and 5) whose ABST evaluations were reviewed. Findings include, but are not limited to:? Record?reviews?of Resident 1, 2, 3, 4, and 5’s ABST evaluations identified the facility used predetermined average times for care elements rather than resident-specific care times as outlined in each resident’s individual service plan. The ABST evaluations did not accurately capture the care time and care elements staff provided to each resident.? Staff 1 (ED) confirmed, during an interview on 03/19/26 at 11:40 am, the facility’s proprietary ABST generated predetermined times for care elements.? The need to ensure established care time was resident-specific rather than a predetermined average was reviewed with Staff 1, Staff 2 (RN), and Staff?15?(RN/MSW) at 3:30 pm on 03/19/26. They acknowledged the findings.??

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

Based on observation,?interview,?and record review, it was?determined?the facility?failed to?follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:? Refer to?C362.

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?C305.?

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

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (5) who had repeated medication refusals. Findings include, but are not limited to: Resident 5 moved into the Memory Care Community in 02/2026 with diagnoses including Parkinson’s disease and dementia. The resident's 02/04/26 through 03/16/26 MARs and current physician orders were reviewed. Staff documented the resident refused carbidopa/levodopa on nine occasions and entacapone on eight occasions, both medications prescribed to manage symptoms of Parkinson’s disease. There was no documented evidence the facility notified the resident’s physician of the repeated medication refusals as required. During an interview on 03/18/26 at 10:45 am, Staff 2 (RN) confirmed she was unable to locate documentation showing the physician had been notified. The need to notify the physician or other practitioner when a resident refused to consent to orders was discussed with Staff 1 (ED), Staff 2, and Staff 15 (RN/MSW) at 3:30 pm on 03/19/26. They acknowledged the findings.

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

Based on interview and record review, it was determined the facility failed to 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 C305.

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

Based on interview and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan and failed to ensure established care time was resident-specific rather than a predetermined average for 5 of 5 sampled residents (#s 1,2, 3, 4, and 5) whose ABST evaluations were reviewed. Findings include, but are not limited to: Record reviews of Resident 1, 2, 3, 4, and 5’s ABST evaluations identified the facility used predetermined average times for care elements rather than resident-specific care times as outlined in each resident’s individual service plan. The ABST evaluations did not accurately capture the care time and care elements staff provided to each resident. Staff 1 (ED) confirmed during an interview on 03/19/26 at 11:40 am, the facility’s proprietary ABST generated predetermined times for care elements. The need to ensure established care time was resident-specific rather than a predetermined average was reviewed with Staff 1, Staff 2 (RN), and Staff 15 (RN/MSW) at 3:30 pm on 03/19/26. They acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

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

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records reviewed from 10/2025 through 03/2026 lacked documentation that drills and fire life safety training were conducted every other month on alternating shifts for the memory care. The need to ensure fire life safety training and drills were conducted on alternating months was discussed with Staff 1 (ED) on 03/16/26 and 03/17/26. The staff acknowledged the findings.

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

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 the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 03/16/26 and 03/17/26 showed the following areas in need of cleaning or repair: * Multiple scuffs, gouges, and scratches were noted to the laminate flooring in the dining room. Scratches were several inches in length at the minimum. There were numerous areas that scratches were deep into the surface of the floor, creating crevices and divots; * Chips, scrapes, and spills were noted on walls in the dining room, club room, and common area bathrooms; * Numerous dark stains of varying sizes were noted on the carpet in common areas and hallways throughout the building; * Numerous striped armchairs were noted with large spills, splatters, and stains on seats, arms, and/or backs of the chairs; * Common area bathrooms had scrapes and dings to walls, discolored or missing caulking around the base of the toilets, and/or cracked floor tiles; and * Several dining room chairs had debris and spills on the seats, arms, and/or backs of the seats. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) on 03/16/26 and 03/17/26. The staff 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.

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

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C362, C420, 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 C305.

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

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals.

Based on observation and interview, it was determined the licensee failed to ensure adequate administrative oversight of facility operations regarding kitchen sanitation practices, which posed a risk to the safety of residents. Findings include, but are not limited to: During the annual kitchen inspection, conducted 11/17/25 through 11/20/25, administrative oversight to ensure adequate food sanitation practices in the facility kitchen was found to be ineffective based on the severity of the citation. 1. A situation was identified where there was a failure of the facility to comply with the Department’s rules that was likely to cause residents serious harm. An immediate plan of correction was requested on 11/17/25 at 12:00 pm in the following areas: OAR 411-054-0030 Resident Services, Meals, Food Sanitation Rule. The facility provided a plan of correction on 11/17/25 at 2:24 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system(s) failure(s) associated with the licensing violation. 2. Refer to C240.

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 in accordance with Food Sanitation Rules, OAR 333-150-000. The facility’s kitchen was observed in an unsanitary condition, with a person in charge without adequate knowledge or training, with multiple failed food safety practices which posed an immediate jeopardy situation that could threaten the health, safety, and/or welfare of residents. Findings include, but are not limited to: Observations of the ALF facility kitchen which prepares all of the facility’s meals and the lunch meal service were completed on 11/17/25 from 10:10 am through 2:30 pm, and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black matter was visible on or underneath the following: * Kitchen entrance threshold floor; * Stainless steel prep tables; * Stainless steel open shelving; * Interior and exterior of ice machine; * Ice machine scoop holder; * Juice machine area by nozzles; * Top of beverage dispensers; * Utility carts; * Hand washing sink; * Stainless steel shelving above hand washing sink; * Legs of prep tables; * Walls and floors throughout kitchen; * All kitchen drains; * Shelving under the steam table; * Interior and exterior of cabinets storing clean dishes; * Steam table wells; * Faucet and handles of prep sink; * Interior and exterior of temperature regulated/insulated carts; * Walk-in cooler floors under metal shelving and in thresholds; * Walk-in cooler metal racks; * Walls in walk-in cooler; * Interior of plastic bin storing fruit and vegetables; * Removable metal racks in walk-in cooler; * Fan cages of walk-in cooler and freezer; * Celling and sprinkler head in walk-in cooler; * Interior and exterior of microwave, convection ovens, and industrial steamer; * Removable hood vents; * Piping/electrical conduit by oven and wall; * Stove top burner plates; * Knobs and handles of stove and grill; * Industrial can opener and housing; * Industrial mixer; * Stainless steel table where mixer was located; * Interiors and exteriors of stainless steel drawers throughout kitchen; * Outsides, lids and handles of trash cans; * Windowsills and screens; * Vents and light fixtures; * White food bin exteriors; * Floors in dry storage; * Oven mitts; * Interior of clear plastic bin storing clean cooking utensils; * Knife holder attached to knives (knives and holder); * Sanitizer dispenser; and * Sides of steam line cabinets. b. The following areas were in need of repair: * A section of wall by the entry to the kitchen threshold was damaged near floor. * Caulking behind the three-compartment sink had black matter build-up and was in need of replacement. * Multiple areas in tile floor had missing grout; c. Scoops and spoons were observed in bulk food containers with handles touching food surfaces. d. Multiple kitchen staff were observed preparing food and/or handling clean dishes without appropriate facial hair restraints as required. Staff 2 (Dining Services Director) had visibly soiled and very dirty outer clothing. Staff 2 was observed to wipe his hands on his outer clothing multiple times during the review. e. Staff 2 was interviewed regarding how often sanitizer buckets were changed and he indicated every four hours, not every two hours or as needed per rule. f. The handwashing sink did not have paper towels to properly dry hands. Facility staff were not able to state when the dispenser had run out of towels. The hand washing sink also had visible debris inside the sink indicating was used for purposes other than hand washing. g. Multiple kitchen staff, including Staff 2, were not observed washing hands as required. This included times where hands were contaminated from touching clothing, other surfaces, and/or handles. h. Multiple food items were observed stored in dry storage, walk-in cooler and/or freezer that were not closed or covered and were exposed to potential contamination. i. A large container of used/dirty/rancid oil was observed stored uncovered under a shelf in the back food prep area. The facility did not have a system to correctly dispose of used cooking oil. Staff 2 indicated that bucket had been there for at least 2-3 months. j. A trash can without a liner and with visible food debris was observed stored in the dry food storage area. k. Staff 2 was preparing a ground beef product for lunch. The product was placed into the steam well without checking the temperature to ensure it had reached 155 degrees F for 15 seconds. Surveyors intervened and asked Staff 2 to check the temperature. It was found ranging between 140-145 degrees F. Staff 2 indicated they often put the products in about 10 degrees under to finish cooking in the steam wells. Surveyors indicated food for service must be fully cooked prior to placement in the steam wells and that food should not be “cooked” in the steam tables. Staff 2 also was not aware that ground beef could not be served at a medium doneness and must be fully cooked (155 degrees F or higher). l. Staff 2 was observed to check food temperatures with a thermometer that was not at a fully cooked temperature and did not sanitize thermometer prior to checking temperatures of fully cooked product, potentially contaminating the fully cooked product. Staff 2 was not observed to sanitize thermometer before, between products, or after use before storing probe in protective cover. m. Multiple kitchen towels were observed stored in various places throughout the kitchen, not in the sanitizer buckets as required. Several were visibly soiled and stiff. Staff 2 was observed to wipe his hands with a kitchen towel without observation of appropriate hand hygiene measures. n. Boxes of food product were observed stored on the floor of the walk-in freezer. In an interview, Staff 2 confirmed the facility had received stock more than 24 hours prior. o. Multiple cutting boards were found heavily scored or stained and in need of replacement. Multiple oven/hot mitts were found damaged with holes and rips. p. Staff 2 was not able to demonstrate knowledge in cleaning practices, effective hygiene practices, effective sanitation practices, correct cooking practices, proper cooling practices, appropriate cold and dry food storage practice, or proper reheating processes. In an interview on 11/17/25 at approximately 12:00 pm, Staff 1 (Executive Director) and Staff 3 (Associate Executive Director) was informed by the Surveyors of the significant sanitation and safety concerns, and that the kitchen would be shut down. The facility was instructed to submit an immediate plan of correction to address the unsanitary and unsafe conditions. Staff 1 had toured the kitchen area with the surveyors and had observed and acknowledged the areas identified and in need of immediate attention/correction. An immediate plan of correction to address the deficient kitchen sanitation practices was requested on 11/17/25 at 12:00 pm. The facility provided a plan of correction on 11/17/25 at 2:24 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system(s) failure(s) associated with the licensing violation. On 11/20/25 at 10:15 am, the surveyors returned to inspect progress of addressing sanitation and poor repair concerns. Surveyors toured areas with Staff 4 (District Director of Operations), Staff 5 (Traveling Dining Services Specialist). Staff 4 and Staff 1 outlined the ongoing training plan for the Person-In Charge and the ongoing oversight of the food service operations. The facility also outlined the plan for a consultation from a Registered Dietitian at least quarterly for an extended amount of time to ensure on going compliance. Facility acknowledged lack of adequate staff for kitchen was a contributing factor to poor sanitation. At that time, it was determined the facility could safely resume food service operations.

Areas of the kitchen and dining room including but not limited to: Floors in the dinning room, chairs, kitchen enterance threshold, prep tables, shelving, ice machine, ice machine scoop holder, juice machine nozzles, beverage dispensers, utility carts, hand waskhing sink, prep tables, walls and floors, drains, steam table, cabnets that store clean dishes, steam table wells, facet hands, insultated cars, walking in cooler racks, walls of walk in cooler, food starage bins, fan cages, ceiling and sprinkeler in walk-in colloer, hood vents, stovetop burner plates, knobs and handles of stove and grill, industrial can opener, industrail mixer/stand, stainless steel drawers throughout the the kitchen windowsills and screens, floors in dry storage, oven mitts, knife holder and sanitizer dispenser. Have been cleaned and will continue to be maintained in good, clean working order. The section of the wall by the entery of the kitchen threshold will be repaired and replaced with a cleanable surface. Caulking behind three-compartment sink has been replaced. Scoops will be stored in designated holder, not in food product. Beard nets have been ordered and are availible to staff with facial hair. Aprons are availible to staff and will be changed when soiled. Hand hygiene training will be completed by all kitchen staff. Sanitizer buckets will be changed every two hours or as needed. Checking/changing paper towels for hand washing sink will be completed on task sheet daily. food items will be closed and/or covered to prevent potential contamination. Oil container has been removed and routine oil disposal oil disposal will be completed. Trash cans will not be stored in dry storage area. Training on reaching proper food temperature completed for all kitchen staff members. New theromometers ordered with disposable covers. Training on the use of these completed for all kitchen staff. All spills will be cleaned and towels will be removed from the floor promptly. Food product will not be stored on the floor. Cutting boards will be replaced. Utensils will be rolled in napkins prior to setting tables. A Registered Dietition will provide quarterly audits and partnership to ensure continued compliance. Staff training on policies and procedures of kitchen operations completed with staff. Weekly audits to be completed by administrator. Documentation of this will be kept in a binder in the kitchen. New task sheets for cleaning tasks presented during all staff meeting. Documentation of this will be kept in a binder in the kitchen. Weekly meetings to review kitchen status with Pro-temp and/or District Director of operations. Weekly audits to be completed by administrator. Documentation of this will be kept in a binder in the kitchen. New task sheets for cleaning tasks presented during all staff meeting. Documentation of this will be kept in a binder in the kitchen. Dinning Services Manger will complete cleaning audits 5 days a week. Manager on duty will complete on his days off. Brookdale Traveling Pro-temp will provide oversight and training for all kitchen staff including Dinning Services Manager. Weekly meetings to review kitchen status with Pro-temp and/or District Director of operations.

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

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

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

see C 240

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 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement program that evaluated services, resident outcomes and resident satisfaction. Findings included, but are not limited to: During the annual kitchen survey, conducted 12/24/24, quality improvement oversight was found to be inadequate to ensure the facility's dining services were maintained in a safe and sanitary condition, following Oregon food code practices and menus as outlined in rule.

Weekly audits to be completed by administrator. Documentation of this will be kept in a binder in the kitchen. New task sheets for cleaning tasks presented during all staff meeting. Documentation of this will be kept in a binder in the kitchen. DSC will complete cleaning audits 5 days a week. Menu chat will held twice monthly where concerns will be addressed. Comment cards and grievance log will be reviewed five times weekly by ED and followed up on in a timely manner

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

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 good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen was completed on 12/27/24 from 10:30 am through 2:30 pm and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Floors throughout kitchen; * Floors in the dining room; * Walk in cooler floors under metal shelving and in thresholds; * Walls throughout kitchen behind prep areas; * Open shelving throughout kitchen; * Interior and exterior of microwave; * Interior and exterior of convection ovens; * Industrial can opener and housing; * Industrial mixer; * Door thresholds with food debris/splatter; * Interiors and exteriors of stainless steal drawers; * Go racks stored in walk in; * Metal racks in walk in cooler and freezer; * Outsides and handles of trash cans; * Small appliances (blender/robot coupe); * Windowsills and screens; * Vents and light fixtures; * White food bin exteriors; * Utility carts; * Dish washing rack dolly/cart; * Interior and exterior of food transportation carts; * Clean area of dish washing station; * Floors and walls in dish washing area; * Kitchen drains; and * Water cooler in dining room; b. The following areas were in need of repair: * Multiple ceramic tiles in threshold of walk in cooler and freezer with cracks; * Multiple areas in dining room walls with missing, chipped or scrapped paint; * The walk in freezer had a large accumulation of ice that was on cardboard boxes and had dripped/froze potentially contaminating food product in the cardboard boxes below the drip/freeze. c. Scoops/spoons observed in bulk food containers with handles touching food surfaces. d. Multiple potentially hazardous foods were found past 7 days from the original preparation date. A large container of chicken salad was dated 11/16/24 and was observed to have visible mold growth on the food product. Another container of tuna salad was dated 11/22/24 and was observed with visible signs of food decay/rot. A container of prepared sandwiches was noted dated 12/14/24, 14 days from preparation date. e. Multiple food items found in walk in cooler noted without proper labels and/or dates when opened or prepared as required. Multiple items were found open and/or not covered/sealed appropriately to protect from potential contamination. f. Multiple kitchen staff were observed preparing food and/or handling clean dishes without appropriate facial hair restraints as required. g. A kitchen employee was observed to have on plastic gloves underneath visibly heavily soiled rubber gloves washing dishes. The staff removed the soiled gloves and handled clean dishes with the visible wet plastic gloves on underneath the soiled rubber gloves. No hand hygiene step was observed between dirty and clean tasks as required. h. A container of hot sauce, a visible dirty metal baking supply, and a to-go coffee cup was observed on the clean side of the dish machine potentially contaminating the clean area of the dish area. The coffee cup was an employee drink and did not contain the appropriate straw or handle as required. i. The kitchen had four red surface sanitizing buckets. These buckets were tested for appropriate surface sanitizing levels. The facility was asked for test strip and a quat 10 strip provided. None of the four buckets registered any concentration of sanitizing solution. Staff 2 (Dining Services Coordinator) was asked to make a fresh bucket and test the solution. The chemical that came from the dispenser did not register any quat sanitation which is what staff 2 thought was the sanitizing chemical. When asked how frequent the buckets were changed staff 2 responded every 3-4 hrs not the every 2 hrs or as needed per rule. Facility indicated they would contact their Eco lab representative to check the dispenser as soon as possible. j. The snack fridge on the unit did not contain a thermometer to ensure food was stored at the appropriate cold food storage temperature. k. A week’s worth of menus was requested at the start of survey, Staff 2 indicated the facility did not currently have 7 days of menus in advance as required. Staff 2 stated they were working on developing the menus as required but was short staffed and had not been able to complete it. Staff 2 indicated they had to change the menu to use up food supply. Staff 2 was asked if residents were notified in advance when menu items changed. Staff 2 stated they did try to let them know if and when they could. Staff 1 (Executive Director) was interviewed and acknowledged the facility currently did not have a system for communicating menu changes with residents per guidelines. At 12:00 pm, the memory care unit was observed and the following was items were noted in need of cleaning; *interior and exteriors of reach in coolers; * Dry cereal bins, * Industrial can opener and housing; * Walls, ceiling and vents in dish washing area with dust and/or splatter; * Interior and exterior of microwave; *Fan blades and cages; * Pot holders; * Top of Dish machine; * Utility carts; * Door seal of reach in freezer with black debris; * Oven in dining room area with food spill debris; The memory care kitchenette had multiple items in reach in cooler that did not have dates when opened or were passed 7 days from preparation dates including a package of hot dogs that were opened 10/22/24. There was a open can of energy drink in the food service area that did not have a lid or a straw and in approved area per rule. Staff 2 (Dining Service Coordinator) toured kitchen areas with surveyor and acknowledged identified areas needing attention. At approximately 2:00 pm, surveyor reviewed above areas with Staff 1 (Executive Director), who acknowledged the findings.

Week at a glance menu, daily menus and weekly snack menu posted. All menus are signed off on by a registered dietitians. Snacks are accessible and available to residents 24 hours a day. Fresh fruit is available in the front lobby. Menu chat held twice monthly. During this meeting resident involvement in menu planning is highly encouraged. All substitutions will posted a accessible to residents prior to the meals via chalk board located outside the dining room in AL and on menu board in MC. Eco lab providing test strips for sanitation buckets that will be changed every two hours. Staff will be trained on this process during all staff meeting. Eco lab representative has been contacted to check the sanitizing chemical dispenser. Kitchen staff will be presented with and trained on updated daily cleaning tasks. Heavily used kitchen equipment/small appliances such as microwave, can opener and mixer have been added to daily and as needed cleaning tasks. Kitchen vents and pipes have been cleaned and added to TELS for scheduled twice a month cleaning. Kitchen window screens have been replaced. Kitchen staff have been trained on use of scoops for food bins. Sign with reminder of this direction can be found located near the bins. Dish washing rack have been cleaned and sanitized. This will be done on an ongoing basis. Floors and walls in dish pit have been cleaned and sanitized. All non-cleanable surfaces will be repaired. This area has also been added to routine cleaning schedule. Community has been contacted 3rd party company to have tiles in walk-in cooler/freezer repaired. This has been completed. Uncleanable surfaces on wall in dining area will be repaired and repainted. Walk-in freezer has been de-iced and added to weekly and as needed task list. Proper food storage and labeling will retrained and is being checked daily with task sheet and overseen by kitchen manager. Beard nets are now available to staff with facial hair and being used as required. Proper use of gloves/hand hygiene has been trained including no double gloving. Personal drinks will have lid/straw as required in kitchen area. Snack fridge now has a temp log and thermometer to ensure proper temp holding. Infection prevention policy binder is available to all kitchen staff. Crandall Corp. Dietitians services have been obtained and to ensure continued compliance. weekly audits to be completed by Administrator. New task sheets for cleaning tasks presented during all staff meeting. DSC will complete cleaning audits 5 days a week. Menu chat will held once monthly where concerns will be addressed. Comment cards and grievance log will be reviewed five times weekly by ED and followed up on in a timely manner.

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

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

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

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.

Based on observation, interview, and record review, conducted during a site visit on 12/17/24, the facility's failure to update an acuity-based staffing tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated all 30 residents were included in the tool and had a completed ABST evaluation. A review of the facility's ABST indicated the following: · The "minimum time needed based on acuity" on day shift was 5.76 direct care staff; on swing shift was 4.02 direct care staff; and night shift was 1.2 direct care staff. · Only 20 of 22 activities of daily living (ADL) had been addressed. A review of the facility's posted staffing plan indicated the following: · Day shift: Four caregivers and two med techs; · Swing shift: Three caregivers and one med tech; and · Night shift: Two caregivers and one med tech; A review of the facility's staff schedule and timecards dated 12/11/24 through 12/17/24, indicated the facility was consistently staffing to their posted staffing plan. A review of Resident 1 and Resident 2's records and ABST profile indicated no discrepancies. Staff 1 (Executive Director) indicated the following; · The facility used a proprietary ABST called PEAR. The tool had not been approved by the State. · One resident required one-on-one assistance. The facility had been scheduling additional staff to meet the need. · Five residents who had required two-person transfers. · The facility's ABST failed to separately list all 22 required ADL questions for each resident. · The facility ABST had only 20 of 22 required ADLs. CS observed day shift was staffed with five caregivers and two med techs. It was determined the facility failed to update an acuity-based staffing tool. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

Based on observation, interview, and record review, conducted during a site visit on 12/17/24, the facility's failure to update an acuity-based staffing tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated all 30 residents were included in the tool and had a completed ABST evaluation. A review of the facility's ABST indicated the following: · The "minimum time needed based on acuity" on day shift was 5.76 direct care staff; on swing shift was 4.02 direct care staff; and night shift was 1.2 direct care staff. · Only 20 of 22 activities of daily living (ADL) had been addressed. A review of the facility's posted staffing plan indicated the following: · Day shift: Four caregivers and two med techs; · Swing shift: Three caregivers and one med tech; and · Night shift: Two caregivers and one med tech; A review of the facility's staff schedule and timecards dated 12/11/24 through 12/17/24, indicated the facility was consistently staffing to their posted staffing plan. A review of Resident 1 and Resident 2's records and ABST profile indicated no discrepancies. Staff 1 (Executive Director) indicated the following; · The facility used a proprietary ABST called PEAR. The tool had not been approved by the State. · One resident required one-on-one assistance. The facility had been scheduling additional staff to meet the need. · Five residents who had required two-person transfers. · The facility's ABST failed to separately list all 22 required ADL questions for each resident. · The facility ABST had only 20 of 22 required ADLs. CS observed day shift was staffed with five caregivers and two med techs. It was determined the facility failed to update an acuity-based staffing tool. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight for the operation of the facility and to ensure the quality of services rendered in the facility. Findings include, but are not limited to: During the relicensure survey, conducted 04/29/24 through 05/03/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity of the citations. 1. A situation was identified which constituted an immediate threat to the health and safety of the residents in the following area: C282: OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching. The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety, and the situations were abated. 2.  Refer to deficiencies in the report.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings included, but are not limited to: During the survey, conducted 04/29/24 through 05/03/24, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective. The need to ensure the facility developed and conducted an ongoing quality improvement program that evaluated services, resident outcome and satisfaction was discussed during the exit interview. No additional information was provided. Refer to the deficiencies in the report.

Based on interview and record review, it was determined the facility failed to investigate incidents to rule out abuse, document all required areas of an investigation, and/or immediately report to the local Seniors and People with Disabilities (SPD) office if abuse could not be ruled out for 4 of 4 sampled residents (#s 1, 2, 3, and 4 ) reviewed for resident-to-resident altercations and unwitnessed falls. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 11/2022 with diagnoses including dementia with behavioral disturbance. A review of the resident's 04/26/24 service plan, 01/29/24 through 04/29/24 progress notes and incident reports for the same time period were completed. Resident 1's service plan identified the resident as having recurrent aggressive and sexually inappropriate behaviors. A review of the resident's records identified the following: * On 01/30/24, progress notes and an incident report noted, "[Resident 1] was rubbing [another resident's] buttocks with [his/her] hand and [the other resident] was witnessed kissing [Resident 1] on [his/her] forehead." An investigation was completed but no report was made to the local SPD office until  02/07/24, eight days after the incident. * On 02/04/24, progress notes and an incident report noted that staff had found another resident lying in Resident 1's bed. Resident 1 was not wearing pants and was standing at the bedside. An investigation was completed, but no report was made to the local SPD office until 02/07/27, three days after the incident. * On 02/05/24, progress notes and an incident report noted, a resident-to-resident altercation in which Resident 1 had slapped another resident with an open hand. An investigation was completed, but no report was made to the local SPD office until 02/07/24, two days after the incident. In addition, the facility failed to ensure the above incidents had been reviewed by the administrator. The need to ensure incidents of abuse or suspected abuse were immediately reported to the local SPD office and promptly investigated was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings. 2. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance. A review of the resident's 04/03/24 service plan, 01/29/24 through 04/24/24 progress notes and incident reports for the same time period were completed. Resident 4's service plan identified the resident as having physical and verbally aggressive behaviors toward other residents and staff. A review of the resident's records showed the following: * On 02/25/24, staff documented in a progress note that Resident 4 had charged and screamed in another resident's face. "[Resident 4] slapped [the resident] in the face and was going to punch [him/her]." [Resident 4] picked up a chair and was going to throw it at [the resident]." * On 03/03/24, staff documented in a progress note Resident 4 was in a resident-to-resident altercation and had obtained a skin tear. Investigations were completed at the time of the incidents; however, the incidents were not reported to the local SPD office. The facility was directed to self-report the incidents to the local SPD office. Confirmation the reports had been sent was received on 05/03/24. The need to immediately report resident altercations to the local SPD office was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings. 3. Resident 3 was admitted to the facility in February 2021 with diagnoses including dementia. Interview and record review revealed the following: * On 02/12/24, Resident 3 experienced an unwitnessed fall with an abrasion to his/her back. The incident was investigated, however, there was no documented evidence of an administrator review of the incident. * On 03/10/24, Resident 3 experienced an unwitnessed fall with fractured ribs. The incident was investigated, however, there was no documented evidence of an administrator review of the incident. On 05/03/24, the need to ensure investigations of suspected abuse were reviewed in a timely manner by the facility administrator was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations) Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings. 4. Resident 2 was admitted to the facility in 09/2016 with diagnoses including dementia. The resident's record, including progress notes and incident reports, was reviewed, and staff were interviewed. The following was identified: A progress note dated 03/05/24 indicated the resident was found on the floor in his/her room with "a laceration on the back of [resident's] head that was bleeding." Staff 1 (Associate Executive Director) confirmed in an interview on 05/03/24 that the incident report dated 03/05/24 did not include an investigation which ruled out abuse or neglect. The surveyor requested the facility report the incident to the local Seniors and People with Disabilities (SPD) office on 05/03/24. Confirmation was provided of the report prior to survey exit. The need to investigate unwitnessed falls with injury to rule out abuse and/or neglect, and to report the incident to the local SPD office if abuse and/or neglect could not be ruled out, was discussed with Staff 1, Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

2. Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes and dementia with behavioral disturbance. Resident 1's most recent quarterly service plan was updated 04/26/24. There was no documented evidence of a quarterly evaluation which corresponded with the 04/26/24 service plan update. In an interview on 05/02/24, Staff 4 (RN/Health and Wellness Director) reported that she had not completed the resident's quarterly evaluation. The need to ensure the facility completed resident evaluations quarterly was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings. 3. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance. Resident 4's most recent quarterly service plan was updated 04/03/24. There was no documented evidence of a quarterly evaluation which corresponded with the 04/03/24 service plan update. In an interview on 05/02/24, Staff 4 (RN/Health and Wellness Director) reported that she had not completed the resident's quarterly evaluation. The need to ensure the facility completed resident evaluations quarterly was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to complete quarterly evaluations for 4 of 4 sampled residents (#s 1, 2, 3, and 4), whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in February 2021 with diagnoses including dementia. Resident 3's most recent quarterly service plan was updated 12/28/23. There was no documented evidence of a quarterly evaluation which corresponded with the 12/28/23 service plan update. On 05/02/24, Staff 1 (Associate Executive Director) reported the service plan dated 12/28/23 was all she had related to a quarterly evaluation for Resident 3. On 05/03/24, the need to ensure a quarterly evaluation was completed timely was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings. 4. Resident 2 was admitted to the facility in 09/2016 with diagnoses including dementia. A review of the resident's record identified his/her quarterly evaluation had not been completed. Staff 4 (RN/Health and Wellness Director) confirmed in an interview on 05/02/24 that she had completed the resident's current service plan, dated 04/06/24, without completing a quarterly evaluation. The need to ensure resident evaluations were completed quarterly, was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans provided clear instructions to staff for 2 of 4 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes and dementia with behavioral disturbance. The resident's 04/26/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan failed to provide clear direction to staff in the following areas: * Frequency of supervision related to behaviors; and * Emergency evacuation ability. The need to ensure service plans included clear direction to staff was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings. 2. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance. The resident's 04/03/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan failed to provide clear direction to staff in the following areas: * Frequency of toileting assistance and brief changes; * Oral care and clear instructions on what staff were to complete; * Pain areas and treatment; and * Emergency evacuation ability. The need to ensure service plans included clear direction to staff was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. 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 that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 3 of 4 sampled residents (#s 1, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: Residents 1, 3, and 4's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of their service plans. On 05/03/24, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure interventions for changes of condition were determined, communicated to staff, and/or were monitored and evaluated for effectiveness for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced changes of condition related to skin, behaviors, and falls. Resident 1's wounds worsened. Findings include, but are not limited to: 1. Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes and diabetic polyneuropathy. a. During the acuity interview on 04/29/24 and interviews with care staff between 04/29/24 and 05/02/24, staff indicated Resident 1 had wounds on both feet. A record review showed the resident's feet were treated by HH until 02/08/24. On 02/08/24, the HH RN left the following wound care recommendations for the facility: Washing the resident's feet at least every other day and apply vaseline or lotion. There was no documented evidence the facility washed the resident's feet every other day or applied lotion to the resident's feet. The facility failed to communicate those instructions to staff. The resident's 01/29/24 through 04/29/24 progress notes and skin documentation indicated the resident experienced the following changes of condition: On 02/14/24, staff documented in a progress note that the resident had a visit from a podiatrist. "Services performed: debridement of nails times ten with use of nail nippers and debulked with [the] use of a dremel. Nursing staff will continue to monitor [resident's] feet on a routine basis. Recommended routine debridement of nail plates at three-month intervals or sooner if any pathological problems occur with the feet. Recommended use of protective shoe gear to prevent incidental damage to the feet." On 03/17/24, staff documented in a progress note that the resident was found on the floor of his/her bedroom. "Staff noticed blood and found wounds on several toes that were bleeding." The resident was sent to the emergency room. Between 02/14/24 and 03/17/24 the facility failed to monitor and document on the progress of the wounds. On 03/23/24 staff documented in a progress note that the resident had fallen. The MT noted the following: "saw some blood from [his/her] feet and checked [his/her] toes and saw some sores and a new open area." On 03/27/24, staff documented in a progress note that the "resident has wounds on [his/her] left foot. Big toes [on left foot were] bleeding and had dry blood build up. MT has cleaned and disinfect. Ring toe is swollen, red and warm to the touch." It was further noted that staff were instructed by the facility RN to put socks and shoes on the resident. The resident was placed on alert charting. On 03/28/24, the RN completed a significant change of condition note related to wounds on toes. The RN noted the following: "[Resident 1] has developed open wounds on [his/her] 2nd, 3rd, and 4th toes on the dorsal aspect of both feet. [S/he] also has a closed, calloused wound on [his/her] right 2nd toe on the bottom. [His/her] big toes are in need of podiatrist nail care. [Resident 1] refuses to wear socks and the wounds are present in the area where [his/her] toes come into contact with the fabric of [his/her] shoes. [Resident 1] is reluctant to have any treatment done on [his/her] toes." The RN noted the resident was very resistant to showering or changing clothes and often slept with shoes on. The RN documented the resident was encouraged to wear socks and noted the resident seemed to understand that his/her shoes were rubbing on his/her toes. It was further noted that an evaluation by the resident's PCP was needed prior to a HH referral. On 04/23/24 the RN and LPN assessed the resident toes and documented the following: "Right foot 2nd toenail appears to have been pulled out some time ago, as the bed is hard and dark pink. There is an abrasion on the top of this toe, appx 0.8cm roughly round. This was cleaned with wound cleanser, dried and a band aid applied. There is a black, hard calloused area on the tip of the toe, slightly medial. 4th and 5th toes have hard scaly thickened areas, pale yellow and brown in color. Several areas of the toes have peeling, thick skin. Resident denies pain anywhere on his feet. Left foot has no open areas, but 3rd and 4th toes both have the same type of hard, scaly thickened areas on the tops and at the base of both. All toes have the peeling thick skin as well." Between 03/28/24 and 04/23/24 the facility failed to monitor the wounds consistent with the resident's evaluated needs and service plan. The RN documented on 04/10/24 and 04/23/24. The 04/23/24 note indicated the resident's sibling was called regarding the importance of the resident to be seen for his/her feet. The sibling had stated that the resident had an appointment on 04/25/24. On 04/25/24 a progress note documented the resident's sibling had transported the resident to an appointment at the Diabetes Care Clinic. It was noted the "diabetic nurse did nail clipping and wound debridement and had instructed the [sibling] to take [Resident 1] to Urgent Care." On 04/26/24 a progress note documented the resident's sibling had transported the resident to urgent care. The resident was diagnosed with an infection and was prescribed an antibiotic. The resident's wounds worsened, and subsequently developed into infection requiring antibiotics. The following deficiencies were identified: * The facility failed to evaluate and document the status of the wounds at the time they assumed wound care from HH. The facility also failed to monitor the progress of the wounds and evaluate the effectiveness of the interventions/treatments; * The facility failed to add the instructions regarding washing the resident's feet at least every other day and applying lotion to the service plan and communicate those instructions to staff; and * The facility failed to monitor the resident's wounds consistent with his/her evaluated needs and service plan. The facility's failure to update the resident's service plan with interventions, communicate to staff and monitor the progress of wounds, resulted in the wounds worsening and subsequently developed into an infection, was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings. b. The resident's current service plan dated 4/26/24, Temporary Service Plans, progress notes dated 01/29/24 through 04/29/24 were reviewed. Interviews with care staff were completed between 04/29/24 and 05/02/24. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution: 02/16/24 - Sexual and aggressive behaviors; 03/17/24 - Fall with skin injuries; 03/23/24 - Fall with injury; and 04/10/24 - Fall due to low blood sugar, resident was sent to the emergency room. On 05/03/24, the need to ensure resident specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored at least weekly, through resolution was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings. 2. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance. The resident's current service plan dated 04/03/24, Temporary Service Plans, progress notes dated 01/31/24 through 04/24/24 were reviewed. Interviews with caregivers were completed between 04/29/24 and 05/02/24. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution: * 02/18/24 - Resident to staff physical altercation. The resident had fallen after hitting a staff member and was sent to the emergency room; * 02/25/24 - Resident to resident altercation; * 03/03/24 - Resident to resident altercation; and * 04/19/24 - Pain in right arm and excessive drooling. The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings. 4. Resident 3 was admitted to the facility in February 2021 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's clinical records, including incident reports, progress notes dated 01/30/24 through 04/29/24, service plan dated 12/28/23, and weight records was conducted. a. Record review indicated the resident experienced a 6.4 pound weight loss from 03/2024 to 04/2024 which constituted a severe 6.60% loss in one month. There was no documented evidence of ongoing monitoring of the resident's weight, no documentation the weight loss was reported to the RN and there were no interventions implemented. On 05/01/24, survey requested a current weight for Resident 3. The weight was noted as an increase of 2.6 pounds. On 05/01/24, the need to respond to significant/severe weight loss with ongoing monitoring, implementation of interventions and evaluation for effectiveness of those interventions was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), and Staff 4 (RN/Health and Wellness Director). They acknowledged the findings. Refer to C280. b. Resident 3's record was reviewed for changes of condition and the following falls with injury were identified: *On 02/12/24, Resident 3 was found on the floor of his/her bedroom with an abrasion near the middle of their spine. There was no evidence the facility monitored the short term change until resolution. *On 03/10/24, Resident 3 was found on the floor of his/her bedroom with complaints of pain to his/her right side. Staff documented in a progress note, on 03/10/24, the resident returned from the local hospital with four fractured ribs. While the facility implemented interventions after the fall, there was no documented evidence the facility monitored the resident consistent with his/her evaluated needs. On 05/03/24, the need to ensure the facility was monitoring short term changes of condition through resolution and significant change of condition with their evaluated needs was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings. 3. Resident 2 was admitted to the facility in 09/2016 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's clinical record including service plan dated 04/06/24, progress notes dated 02/01/24 through 04/23/24, and weight records was conducted. a. Weight records from 12/19/23 through 04/08/24, reviewed on 04/29/24 indicated the resident weighed: * 09/01/23: 129.0 lbs; * 09/08/23: 132.8 lbs; * 10/08/23: 121.2 lbs; * 12/19/23: 118.0 lbs; * 01/09/24: 124.8 lbs; * 03/01/24: 119.0 lbs; and * 04/08/24: 118.0 lbs. An RN assessment dated 03/05/24 noted a 13.8 pounds weight loss or 10.4% of his/her body weight. The assessment noted the following interventions:   * Second helpings; and * Substitute calorie rich food if not interested in what s/he was served. There was no documented evidence the interventions were communicated to staff. On 05/02/24 Staff 4 (RN/Health and Wellness Director) reported she had filled out a temporary service plan for the interventions but did not know where it was. The current service plan dated 04/06/24 did not identify the interventions. On 04/29/24 Resident 2 was observed during lunch to eat 100% of his/her puree meal and was not offered seconds. On 04/30/24 Resident 2 was observed during lunch to eat 100% of his/her meal, was offered seconds, and was then observed to eat 100% of the 2nd entrée that was provided. A staff member asked Resident 2 if they would like more, to which the resident nodded and the staff confirmed, but no third helping was provided. In addition, staff initialed on the MAR they were administering a MightyShake nutrition supplement with meals however none was observed with lunch on 04/29/24 and 04/30/24. On 05/01/24 a current weight for Resident 2 was requested and provided, which identified the resident as continuing to lose weight, at 114.8 pounds. Between 04/08/24 and the time of the survey, 5/1/24, Resident 2 lost an additional 3.2 pounds. The need to ensure interventions for significant changes of condition were communicated to staff, and monitored consistent with the resident's evaluated needs, was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings. b. The following short-term change of condition lacked documentation of progress noted at least weekly through resolution: * 03/05/24 - wound on back of head. The need to ensure short term changes of condition were monitored at least weekly through resolution was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a significant change of condition was assessed by an RN, with resident status documented, and interventions developed as a result of the assessment, for 1 of 3 sampled residents (#3) who experienced a significant change of condition. Findings include, but are not limited to: Resident 3 was admitted to the facility in February 2021 with diagnoses including dementia. Review of Resident 3's weight records from 11/2023 through 04/2024 showed the following: On 03/08/24, the resident weighed 95.6 pounds and on 04/08/24 the resident weighed 89.2 pounds. The resident experienced a 6.4 pound weight loss from 03/2024 to 04/2024 which constituted a severe 6.6% loss in one month and required and RN assessment. There was no documented evidence the RN had assessed the status of the resident, documented findings, and developed interventions as a result of the assessment. Resident 3 was observed independently eating lunch on 04/29/24 and breakfast on 04/30/24. The resident ate over 50% of the meals provided. On 05/01/24, survey requested a current weight for Resident 3 and weighed 91.8 pounds. This was an increase of 2.6 pounds from their 04/08/24 weight. On 05/01/24, the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), and Staff 4 (RN/Health and Wellness Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by an RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in Chapter 851, division 047 for 1 of 1 sampled resident (#1) and two unsampled residents who received insulin injections by a facility unregulated assistive person (UAP). These residents were at risk for harm related to potential medical complications from the lack of an RN assessment of the resident's condition, UAP training, and supervision to ensure safety and accuracy of insulin administration. Findings include, but are not limited to: Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions, and outcomes pursuant OAR 851-045, including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client. During the acuity interview on 04/29/24, Resident 1 was identified as receiving both sliding scale and scheduled insulin by facility UAPs. In an interview with Staff 4 (RN/Health and Wellness Director) on 04/30/24, she reported that in addition to Resident 1, two other residents also received insulin. Resident 1's 04/01/24 through 04/29/24 MAR noted the resident received routine insulin every morning and at bedtime, plus sliding scale insulin before breakfast, lunch, and dinner. The MAR identified nine facility UAPs that administered insulin to the resident during the month of April. A progress note dated 04/30/24 by the RN noted a medication error had occurred on 04/29/24. The resident had an order for 50 units of Lantus scheduled at bedtime and a sliding scale insulin Novilin R before meals. The resident's blood sugar was 298 and reference to the sliding scale order the resident should have received 10 units of Novilin R. The RN documented, "The MT instead gave 10 units of Lantus and 50 units of Novilin R" instead of the ordered 50 units of Lantus and 10 units of Novilin R. In an interview on 05/01/24 Staff 14 (MT/Resident Care Assistant) and Staff 16 (MT), two of the UAPs who administered insulin, revealed they had not been delegated. Upon review of the delegation binder, there was no documented evidence that any of the residents receiving insulin injections had documentation that the resident's condition was stable and predictable or that the determination of frequency of the resident should be reassessed, including rationale. There was no documented evidence any of the facility UAPs had been delegated by an RN, including: * Rationale why the task could be safely delegated; * Skills, abilities, and willingness of the UAP to complete the task; * Task was taught to the UAP, and they were competent to safely perform task; * Written instructions available, including risks, side effects, response, and risk factors; * UAP were taught the task was client specific and not transferable; * Determination of frequency of the UAP should be supervised and reevaluated, including rationale; and * RN takes responsibility for delegating task and ensures supervision will occur for as long as RN was supervising performance. In an interview on 04/30/24 Staff 4 was unable to find documented evidence that delegation was completed according to OSBN Division 47 rules. On 05/01/24 at 9:19 am, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Associate Executive Director), Staff 4 and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the above findings. On 05/01/24. the survey team requested an immediate plan to ensure insulin was administered by licensed or delegated staff in accordance with OSBN Division 47 Rules. On 05/01/24 at 1:00 pm, a plan to address the delegation issue which included licensed staff administering insulin until delegation was completed, was accepted and the situation was abated.

Based on interview and record review, it was determined the facility failed to have a system to coordinate care with outside providers to ensure continuity of care for 1 of 2 sampled residents (#1) who received outside services. Findings include, but are not limited to: Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes with diabetic polyneuropathy. A review of progress notes and "Outside Provider Communication Forms" from 01/23/24 through 02/08/24 identified the resident had been receiving HH wound care until 02/08/24, which included the following information made by the provider: * 01/23/24: "Check [left] great toe, clean [and] cover with band aide. Encourage resident to wear socks daily and HH [Skilled Nurse] to assess wound once a week;" * 01/26/24: "Please redress wound to left foot if it becomes dislodged. Apply betadine and bandage. Also, remove bandage and reapply if wet. [The] wound is macerated from being very wet;" * 01/29/24: "Keep wound dry and covered;" * 02/01/24: "Replace bandage if it is soiled/dislodged;" and * 02/08/24: "Recommending washing [resident's] feet at least every other day and applying Vaseline or lotion. If wounds on feet reopen, feel free to contact [HH] to come back in. Nurse moving to PRN [as needed]." There was no documented evidence the facility reviewed the outside provider information, updated the resident's service plan, informed staff of the new interventions, or implemented the treatment. In an interview on 05/02/24, Staff 4 (RN/Health and Wellness Director) reported she was unaware of the above information left by the outside provider. Staff 4 further indicated that the information and recommendations had not been added to the resident's service plan nor communicated to staff for implementation. The need to ensure the facility coordinated care with outside providers to ensure continuity of care was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Residents were put at risk related due to lack of delegation. The findings constituted an immediate plan of correction for the health and safety of the residents. Findings include, but are not limited to: Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following area: C282: OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching. On 05/01/24 at 9:00 am, the survey team requested an immediate plan of correction to address the issues identified. A plan was developed and at 1:00 pm was accepted by the team. The immediate jeopardy situation was abated. Refer to C282.

2. Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes and dementia with behavioral disturbance. The resident's MAR, dated 04/01/24 through 04/29/24, and physician's orders were reviewed. Resident 1 had a physician's order to report to the licensed nurse if CBG was less than 80 or more than 400. Between 04/01/24 and 04/29/24, Resident 1's CBG was less than 80 on eleven occasions. There was no documented evidence the facility notified the licensed nurse. The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings. 3. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance. The resident's MAR dated 04/01/24 through 04/29/24 and physician orders were reviewed, and identified the following medications did not have signed orders in the record: * Candesartan cilexetil 32 mg for high blood pressure; * Donepezil 10 mg for dementia; * Memantine 5 mg for dementia; * Sertraline 25 mg for depression; * Acetaminophen 500 mg for pain; * Olanzapine 2.5 mg for behaviors; * Guaifenesin 20 ml for cough; * Haloperidol 0.5 mg PRN for agitation; and * Hydrocodone 0.5 mg PRN for pain. During an interview on 04/03/24, Staff 4 (RN/Health and Wellness Director) acknowledged the resident did not have signed physician orders. Staff 4 stated the resident had recently switched providers and the new provider had been at the facility on 05/02/24; however, the provider failed to leave signed orders. Staff 4 was working with the provider to obtain current signed orders. The need to have signed physician orders for all medications administered by the facility was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's record for all medications the facility was responsible to administer, and medication and treatment orders were carried out as prescribed for 3 of 4 sampled residents (#s 1, 2, and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 09/2016 with diagnoses including dementia. The resident's MAR dated 04/01/24 to 04/29/24 was reviewed, and identified the following: a. In an interview on 04/29/24, Staff 1 (Associate Executive Director) reported physician orders for Resident 2 were unable to be located, and that hospice would be faxing orders to the facility. A fax transmission dated 04/29/24 with physician orders signed 04/29/24 was provided on 04/30/24. b. Resident 2 had an order for morphine sulfate 20 mg/ml solution .5 ml (10 mg) by mouth every hour as needed for pain or shortness of breath. On 04/21/24 the MAR documented .25 ml was administered, which corresponded to the narcotics log. In an interview on 05/02/24, Staff 4 (RN/Health and Wellness Director), confirmed that she had administered less than the prescribed dose. The need to ensure written, signed physician orders were in the resident's facility record, and that physician's orders were followed, was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure staff attempted non-pharmacological interventions and documented they were ineffective prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#4) who was prescribed a PRN psychotropic medication. Findings include, but are not limited to: Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance. A review of Resident 4's MAR, dated 03/01/24 through 04/29/24, indicated the resident was prescribed haloperidol PRN, 0.5 mg every four hours for behaviors and agitation. Resident 4 was administered haloperidol on 03/18/24, 03/19/24, 03/31/24, and 04/10/24. There was no documented evidence non-pharmacological interventions were attempted with ineffective results prior to administration. In an interview on 05/02/24, Staff 14 (MT/Resident Care Associate) confirmed there was no documented evidence on the MAR that showed non-pharmacological interventions were attempted with ineffective results prior to administration. The need to document that non-pharmacological interventions were attempted without success prior to administering a PRN psychotropic medication was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: The facility posted staffing plan indicated the facility staffing levels were: * Day shift 2 MT's and 4 CG's; * Evening shift 1 MT and 3 CG's; and * Night shift 1 MT and 2 CG's. Review of the facility schedule for the month of April 2024 indicated the facility was staffing 2 MT's and 3 CG's for day shift. During interviews on 05/03/24, Staff 11 (Resident Care Associate), Staff 14 (MT), and Staff 17 (Resident Care Associate) indicated when the facility had 2 MT's and 3 CG's, the facility was understaffed and some of the scheduled showers were not always completed. Some resident showers got delayed to swing shift or the resident was first for showers on day shift the following day. On 05/03/24, the need to ensure the facility had adequate staff to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings. Refer to C361.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to: The facility's ABST was reviewed on 05/01/24. There was no documented evidence all 22 required activities of daily living were addressed separately on the ABST being used by the facility. The need to use an ABST which addressed all the 22 activities of daily living for each resident and the amount of staff time needed to provide care in each area was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. This is a repeat citation. Findings include, but are not limited to: The facility's ABST was reviewed on 09/04/24. There was no documented evidence all 22 required activities of daily living were addressed separately on the ABST being used by the facility. On 09/04/24, the need to use an ABST which addressed all the 22 activities of daily living for each resident and the amount of staff time needed to provide care in each area was discussed with Staff 21 (Associate Executive Director), Staff 2 (Executive Director), and Staff 3 (District Director of Operations). They acknowledged the findings.

1. As we continue to partner with DHS on reviewing our ABST tool, we will continue to staff according to our Brookdale acuity based staffing tool. 2. Our home office team will continue to establish proper communication with DHS regarding The ABST tool and the 22 elements that make up the ABST tool, we will continue to staff at or above staffing levels currently identified in our tool. 3.  This will be evaluated by the Health and Wellness Director/Resident Care Coordinator to ensure that proper staffing levels are scheduled according to the 22 elements to ensure the scheduled and unscheduled needs of the residents are being met. 4. The Executive Director is responsible to ensure that our staffing levels are appropriate as defined by our staffing tool

Based on record review and interview, it was determined the facility failed to ensure 2 of 2 sampled newly hired direct care staff (#s 13 and 14) completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 05/02/24 and 05/03/24. The following deficiencies were identified: Staff 13 (Resident Care Associate) and Staff 14 (MT/Resident Care Associate), hired 02/16/24 and 02/01/24 respectively, did not have documented evidence of having completed abdominal thrust training. The need to ensure staff completed all required training as specified in the OARs was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were in good repair. Findings include, but are not limited to: Observations of the facility on 04/29/24 and 05/03/24 identified the following areas in need of repair: *Coffee Bar and Dining room floors had gouges and scrapes; and *Coffee Bar and Dining room chairs were worn down to bare wood. On 04/30/24, an environment tour was conducted with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 5 (Maintenance Manager). They acknowledged the findings.

Concerns were identified in the following areas and the facility was provided with technical assistance: H 1518: Individual Door Locks: Key Access OAR 411-004-0020 (2)(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C150, C156, C231, C360, C361, and C513.

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 361.

See correction C361

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: a. Situations were identified where there was a failure of the facility to comply with the Departments rules that caused or were likely to cause an immediate threat to residents' health and safety. An immediate plan of correction was requested in the following area: C282: OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching. b. Refer to C252, C260, C262, C270, C280, C290, C300, C303, and C330.

Based on interview and record review, it was determined the facility failed to ensure activity evaluations addressed all required components and individualized activity plans were developed for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3 and 4's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect one or more of the following required components: * Residents' current preferences; * Abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. There was no specific activity plan, reflecting the residents' activity preferences and needs, which detailed what, when, how and how often staff should offer and assist each resident with individualized activities. The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure residents had access to an enclosed, secured outdoor area. Findings include, but are not limited to: Observations of the facility interior on 04/29/24 revealed interior courtyard doors were locked, preventing residents from entering and exiting without staff assistance. There were no observations of inclement weather during that time. During an interview on 04/29/24 Staff 11 (Resident Care Associate) reported the interior courtyard doors were always locked. During an interview on 04/29/30 Staff 5 (Maintenance Manager) reported the interior courtyard doors have always been locked, and care associates are the ones who let residents in and out to the courtyard. On 04/30/24 the need to provide access to secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (Associate Executive Director) and Staff 5 (Maintenance Manager) . They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure its re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 361.

See correction C361

The findings of the re-licensure survey, conducted 04/29/24 through 05/03/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to Home and Community Based Services 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 A situation was identified where there was a failure of the facility to comply with the Department's rules which was likely to cause residents serious harm. An immediate plan of correction was requested in the following area: C282: OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching The facility put an immediate plan of correction in place during the survey and the situation was abated.

The findings of the first re-visit to the re-licensure survey of 05/03/24, conducted 09/03/24 through 09/04/24, 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 second re-visit to the re-licensure survey of 09/04/24, conducted 04/10/25, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:   Observation of the facility ALF kitchen was completed on 03/12/24 from 11 am through 3:30 pm and the following was identified:     a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:   * Floors and walls under dish machine; * Floors throughout kitchen; * Walk in cooler floors/corners/edges/walls; * Walls throughout kitchen; * Fans and metal cages of fans; * Reach in coolers and freezers; * Open shelving throughout kitchen; * Interior and exterior of microwave; * Interior and exterior of convection ovens; * Exterior and interior of steamer; * Range top, grill top; * Metal shelves storing pots/pans/dishes; * Knobs of steam table; * Steam table wells; * Cabinet with plate warmer; * Industrial can opener and housing; * Steamer with scale build up and dirty on interior and exterior; * Industrial mixer; * Door thresholds with food debris/splatter; * Interiors and exteriors of stainless steal drawers; * Go racks stored in walk in; * Metal racks in walk in cooler; * Freezer fan cages; * Outside and handles of trash cans; * Small appliances (blender/robot coupe); * Ice scoop holder; * Window seal and screens; and * Kitchen drains. b. The following areas were in need of repair:   * Hole in wall under prep counter where cutting boards stored; * Three compartment sink faucet with leak; * Spring loaded sprayer broken and sitting at bottom of sink; * Caulking behind hand washing sink and ware washing area with black mold like substance; * Pipe from wall next to large fan with gap needing sealed; and * Sprinkler in walk in cooler leaking. c. Scoops/spoons observed in bulk food containers with handles touching food surfaces. Coffee filters stored uncovered and open to potential contamination. d. Multiple cutting boards and cutting surfaces were found heavily stained and scored. Multiple pans/utensils with damage and wear needing to be replaced. e. Multiple food items found in walk in cooler without proper labels and/or dates as required. Items found open or not sealed appropriately to protect from potential contamination. f. Multiple food packages were found open in dry storage. g. Shell eggs and liquid eggs stored over box of "fresh greens". Cardboard box of food items with visible wet debris. Staff stating sprinkler in walk in leaking. h. Multiple cooking/prep dishes were not stored inverted as required and were observed to have visible debris in them.   i. Large meat roast observed being thawed under cold running water upon entry to kitchen. These roasts were then observed at 12:25 on a large pan on a go rack in the main kitchen. Again at 1:35 pm these meat roasts were still observed out of refrigeration on the pan on the go rack. j. Cardboard and recyclables were not stored appropriately and were not separate from food preparation areas. Staff 2 indicated they did not have a good space to store them until taking out to garbage area. k. At 12:05 a staff member entered into kitchen and got ice out of ice machine. The staff member did not wash hands and did not have their hair restrained as required. At 12:25 pm, the memory kitchen area was observed and noted the following areas in need of cleaning: Floors, plastic and metal shelves, toaster, utility carts, reach in fridges/freezers, walls, drains, hand washing sink, reach in oven. The ice machine lid was broken and did not close appropriately, falling to the floor when opened. The dish machine temperature gauge was not functioning properly and was not reaching the required 180 degrees F as required. Surveyor checking temperature with temp strips and the sanitation was validated, however no one was aware the gauges were not operating correctly. Facility staff were documenting temperature readings at 160-180 for final rinse temperatures. Staff 2 acknowledged the temperatures should be 180 and that staff had not alerted them to any temperatures under that requirement. Staff 2 (Dining Service Coordinator) toured kitchen areas with surveyor and acknowledged identified areas needing attention. At approximately 3:00 pm, surveyor reviewed above areas with Staff 1 (Administrator), who acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:   Observation of the facility ALF kitchen was completed on 05/13/24 from 10:15 am through 12:45 pm and the following was identified:     a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:   * Ceiling vent near prep area * Floors throughout kitchen; * Walls throughout kitchen; * Fans and metal cages of fan by serving area; * Open shelving throughout kitchen; * Interior and exterior of microwave; * Interior and exterior of convection ovens; * Exterior and interior of steamer; * Range top, grill top; * Metal shelves storing pots/pans/dishes; * Steam table wells; * Industrial can opener housing; * Steamer interior and exterior; * Industrial mixer; * Door thresholds with food debris/splatter; * Interiors and exteriors of stainless steel drawers; * Window sill and screens; and * Kitchen drains. b. The following areas were in need of repair:   * Areas by electrical conduit/pipes with gaps. c. Scoops observed in bulk food containers with handles touching food surfaces. d. Multiple food items found in walk-in cooler without proper labels and/or dates as required. Container of cut tomatoes was found stored in walk-in cooler. It was dated 04/30/24 multiple days past seven days that is allowed per rule. e. Multiple food packages were found open in dry storage without open dates. f. Thawing meats were not stored correctly according to appropriate cook to temps to prevent potential cross contamination. Whole pork roasts were noted to be stored directly under ground meat products. At approximately 11:15 am, the memory kitchen area was observed and noted the following areas in need of cleaning: Floors, microwave, can opener and housing, toaster, utility carts, steam table wells, and reach in fridges/freezers. The ice machine lid was open exposing ice to potential contamination. Kitchen staff were interviewed and they were not able to correctly state the proper dish rise sanitation temperature. Staff stated rinse temperatures were ranging from 160-170 degrees F. Staff indicated appropriate sanitizing temperature was 170 degrees. Facility dishwashing temperature records documented 22 instances since 05/01/24 where the rinse temperature was under the required 180 degrees to effectively sanitize dishes. Staff 2 (Dining Service Coordinator) toured kitchen areas and Staff 3 (MC Administrator) toured memory care kitchenette with surveyors and acknowledged identified areas needing attention. At approximately 12:30 pm, surveyors reviewed above areas with Staff 1 (Interim Executive Director), who acknowledged the findings.

- Floors throughout the kitchen cleaned and added to daily checklist -Walls throughout the kitchen cleaned and added to daily checklist Open shelving throughout kitchen cleaned and added to daily checklist Interior and exterior of microwave cleaned and added to daily checklist Interior and exterior of convection ovens cleaned and added to daily checklist Exterior and interior of steamer cleaned and added to daily checklist Range top, grill top cleaned and added to daily checklist Metal shelves storing pots/pans/dishes cleaned and added to daily checklist Steam table wells cleaned and added to daily checklist Industrial can opener housing cleaned and added to weekly checklist Industrial mixer cleaned and added to daily checklist Door threshholds with food debris/splatter cleaned and added to daily checklist Interiors and exteriors of stainless steel drawers cleaned and added to weekly checklist Window seal and screens cleaned and added to weekly checklist Kitchen Drains cleaned and added to weekly checklist -Areas with electrical conduit pipes that have gaps will be filled in by Maintenance staff by 5/31/24 Proper labeling of all food items will be done by kitchen staff and be monitored daily Dry storage items that are opened will be labeled with open dates and monitored daily Storage scoops will be put up and not sitting in food bins and monitored daily Thawing meats will be stored according to the food storage heirarchy and monitored daily **Staff will be retrained on the following: -Proper storage of scoops in bulk food containers -Proper labeling and storage of food in both dry storage and in refrigerators and freezers -Food storage heirarchy Memory care kitchen: -Floors, Will be cleaned and mopped daily -microwave, will be cleaned weekly -can opener and housing will be cleaned weekly -toaster will be cleaned weekly -utility carts will be cleaned daily -steam table wells will be cleaned weekly -reach in fridges/freezers. Will be cleaned monthly -The ice machine lid will remain closed -Education on use of dish sanitizer was provided by ECOlab on 6/15/24 and temps over 180 are consistently reached and recorded. All Items will be monitoried by the ED and Dining Services Manager.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:   Observation of the facility ALF kitchen was completed on 07/25/24 from 12:00 pm through 1:45 pm and the following was identified:     a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:   * Floors throughout kitchen; * Fans and cages in walk in cooler; * Floors in walk in cooler; * Open shelving throughout kitchen; * Interior and exterior of convection ovens; * Exterior and interior of steamer; * Metal shelves storing pots/pans/dishes; * Baking "go" racks; * Number 10 can storage racks; and * Kitchen drains. b. Scoops were observed in bulk food containers with handles touching food surfaces. c. Box of frozen hamburger patties were found open and uncovered in the walk in cooler. On 07/25/24, Staff 2 (Dining Service Coordinator) toured the kitchen and acknowledged the findings.  At approximately 1:30 pm, surveyor reviewed above areas with Staff 1 (Interim Executive Director) and Staff 3 (Memory Care Administrator), who acknowledged the findings.

2.  Executive Director and Dining Serivces Coordinator will audit areas of focus as outlined in plan of correction, inservice staff as needed on kitchen cleanliness checklists, and inservice staff on proper food storage. 3. Areas of correction wil be audited weekly 4. Eecutive Director and dining Services Coordinator are responsible for monitoring and ongoing compliance.

Based on record review and interview, it was determined the facility failed to ensure 2 of 5 sampled staff (#s 2 and 3), who prepared food had active food handlers certificates. Findings include, but are not limited to: On 03/12/24 employee records were requested and reviewed to ensure staff had active food handlers cards on file. There were two employees, Staff 2 (Dining Services Coordinator) and Staff 3 (Cook) whose food cards could not be located. Staff 1 (Executive Director) acknowledged the need to have active food handler cards on hand for these individuals.

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

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 C240

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

see Plan of Correction for C240

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

Refer to C240

Based on interview, observation, and record review, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240.

1. Food spills,splatters,loose food, trash debris, and dust/dirt floors throughout kitchen, including floors in walk in cooler and ares under open shelving will be swept and mopped twice daily. Baking "go" racks, Number 10 storage racks, and metal shelves storing pots/pans/dishes will be pressured washed by 8/14/2024. Interior and exterior of convection ovens will be cleaned by 8/12/2024. Exterior and interior of steamer has been cleaned as of 8/4/2024. Kitchen drains have been cleaned as of 8/4/2024. Fans and cages in walk in will be cleaned as 8/12/2024. Scoops for bulk food storage have been removed from bins and signage posted for staff reference on preventing handles from touching food as of 8/8/2024. 2.  Executive Director and Dining Services Coordinator will audit areas of focus as outlined in plan of correction, inservice staff as needed on daily kitchen cleanliness checklists, use and storage of bulk food scoops. and inservice staff on proper food storage. 3. Areas of correction wil be audited weekly and as needed. 4. Executive Director and Dining Services Coordinator are responsible for monitoring and ongoing compliance.

The findings of the kitchen inspection, conducted 3/12/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 03/12/24, conducted 05/13/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second re-visit to the kitchen inspection of 03/12/24, conducted 07/25/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

The findings of the third revisit to the kitchen inspection of 03/12/24, conducted 09/19/24 and 09/20/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview,conducted during a site visit on 06/14/23, it was confirmed the facility failed to provide three daily nutritious, palatable meals. Findings include, but not limited to: In an interview on 06/14/23, Staff 2 (Caregiver) stated there were residents who complained about meals being late and often cold, however, the food was provided by the ALF and if the food was late it was because the ALF did not deliver the food on time, or the MCC dietary aide needed to rewarm the food prior to serving the meal. Meal service was from 12:00 pm-1:00 pm, and residents were usually served within 30 minutes. In an interview on 06/14/23, Staff 3 (Dietary Aide) stated s/he turned on the steam table 30 minutes before the meal, however, today s/he was unable to. S/He turned the steam table on when the food was placed inside the serving line. On 06/14/23 CS observed the following: ·11:41 am- food delivered to MCC kitchen. ·Five staff assisted with meal service with 18 residents in attendance. ·11:47 am-Staff 3 was taking temperatures of food provided, -BBQ beef tips: 168-degrees Fahrenheit -Cod: 133-degrees Fahrenheit -Vegetable mix. cauliflower, carrots, and broccoli: 169-degrees Fahrenheit -Brussels sprouts: 169-degrees Fahrenheit -Sweet potato fries: 155-degrees Fahrenheit -Baked beans: 161- degrees Fahrenheit ·No steam was observed coming from the steam table or the food. ·12:03 pm-Residents were offered small bowls of cantaloupe. ·12:06 pm- First meals entered dining room and were served to residents. ·12:10 pm- A resident asked for salt and pepper for their meal, which staff provided within minutes of the request. ·No residents were overheard complaining about the temperature of the food or the service time. ·12:18 pm- All residents had been served in the dining room. ·At the same time, a sample plate was provided to CS. The plate consisted of BBQ beef, cod, baked beans, steamed vegetables such as cauliflower, carrots, broccoli, brussels sprouts, and sweet potato fries. All food except the baked beans were cold when sampled. It was confirmed the facility failed to provide palatable meals. On 06/14/23, the findings were reviewed with and acknowledged by Staff 1 (Administrator). Verbal Plan of Correction: Staff 1, daily will have the dietary aide turn on the steam table before meal service by creating a log, in addition, s/he is looking into buying a warmer box to transfer food over from ALF to MCC. Will purchase the warmer box within the next month.

Based on observation and interview, conducted during a site visit on 06/14/23, it was confirmed the facility failed to ensure the glass and area surrounding the fireplace did not exceed 120-degrees Fahrenheit. Findings include, but are not limited to: On 06/14/23, CS took the temperature of the surrounding area of the fireplace. The temperature gage read 289-degrees Fahrenheit on one occurrence and 337-degrees Fahrenheit on the second. On 06/14/23, an interview with Staff 1 (Administrator) and Staff 4 (Maintenance Director) explained the facility has a TELS system to record the temperature of the fireplace weekly but that it has not been completed recently due to the facility not having a consistent maintenance director. CS observed Staff 4 take the temperature of the fireplace with his/her own temperature gage and the temperature was 223-degrees Fahrenheit. Both Staff 1 and Staff 4 acknowledged the temperature of the fireplace was higher than 120-degrees Fahrenheit. It was confirmed the facility failed to ensure the glass and area surrounding the fireplace must not exceed 120-degrees Fahrenheit. On 06/14/23, the findings were reviewed with and acknowledged by Staff 1 and Staff 4. Verbal plan of correction: Staff 4 called a vendor out before CS left the facility and stated they would be coming out on 05/22/23 to fix the temperature or the fireplace. Once the new maintenance personal is trained and working on their own, the ED and the maintenance person will do weekly checks for the temperature.

The findings of the on-site investigation, conducted on 06/14/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. 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 Notes on Abbreviations: " The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. " Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate. " Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. " If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include: During an interview on 11/2/2022, Staff #1 (S1) stated,  "I did not keep up with the required posting of the staffing plan when the acuity changed. " During an unannounced site visit on 11/2/2022, Compliance Specialist (CS) observed 3 Caregivers (CG) and 1 Med Tech (MT) working during the day shift. A review of the facility posted staffing plan and the facility ' s Acuity Based Staffing Tool (ABST) indicate that the facility staffing plan does not match the ABST. The above information was shared and acknowledged by S1 and S2 on 11/2/2022. Plan of Correction: S1 stated on11/14/2022 that the facility does staff to acuity, currently the posted staffing plan at the entrance has been updated to read 3 CG and 2 MT for day shift and going forward the designee will update this daily.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, food was stored properly and surfaces were sanitized in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the MCC kitchen, food storage areas, food preparation, and food service on 08/11/22 revealed: * The following areas needed cleaning or repair:   - The interior of the microwave oven had food debris;   - A box fan had lint on the grate;   - There was black mold on the wall above the warewashing dish area;   - A piece of corner trim to the right of the warewashing area had come loose from the wall; and   - Dust pans had accumulated dried debris. * Opened and leftover food items that were stored in the refrigerator were not consistently dated. * The kitchen lacked test strips for determining if the sanitizing solution used to wipe down surfaces was prepared properly. The findings were reviewed with Staff 2 (Dining Services Coordinator) on 08/11/22 at 1:30 pm. He stated his previous supervisor had not trained him on how to date food, and he had not been provided with chemical test strips. The findings were reviewed with Staff 1 (Executive Director) on 08/11/22 at 2:45 pm. He acknowledged the areas needing cleaning, and the need for additional training for kitchen staff.

1)Community will institute a weekly cleaning schedule that all kitchen staff will be trained on.    2) Kitchen staff will need to sign off that they have completed their portion of cleaning. 3) Dining Service Coordinator will monitor the cleaning schedule and hold kitchen staff accountable and retrain, if needed 4) Microwave oven will be cleaned daily as needed 5) Fans and covers will be cleaned in walk in refrigerator 6)Wall by dishwashing machine will be inspected and if mold is detected, it will be remediated and replaced 7) Corner trim near warewashing area will be repaired 8) All dustpans to be cleaned daily 9) Training will be held with all kitchen staff on proper food storage and label procedures and documented 10) Test Strips will be ordered for santizing solution and checked throughout the day as needed to verify sanitation standards

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, food was stored properly and surfaces were sanitized in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the MCC kitchen on 11/22/22 revealed: The following areas needed cleaning or repair: *The interior of the microwave, refrigerators, freezers, and oven had food debris; *The top of the ware-washing machine had food and debris build-up on it; *There was black matter on the wall above and behind the ware-washing dish area; *A piece of two corner trim pieces to the right of the ware-washing area had come loose from the wall; and *Dust pans had numerous ants, debris, and food matter on it. Multiple opened and leftover food items that were stored in the refrigerators were not consistently labeled and/or dated. On 11/22/22, the findings of the MCC kitchen inspection were discussed with Staff 4 (Executive Director), Staff 5 (Assistant Executive Director), and Staff 6 (Cook). They Acknowledged the findings.

Facility will provide written training to all dining staff with the cleaning schedule, touching on all parts noted in re-survey. Dining Services Manager, Memory Care Administrator will audit the memory care kitchen, food storage, and dining areas and the signed cleaning log daily. Daily Dining Services Manager

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the ALF main kitchen and food storage areas on 2/3/23 identified the following:    * Splatters, spills, drips, dust and/or debris were observed on:   - Floors behind, underneath and beside equipment and open shelving;   - Vents and fire sprinklers;   - Grill top, back splash and behind grill;   - Stove top, exterior and interior of regular and convection ovens;   - Ceiling and wall of walk in cooler;   - Cooling fan covers in freezer;   - Walls behind juice machine and by entrance/exit door to dining room;   - Open shelving above steam table and where spices were stored;   - The can opener blade and casing;   - Interior and exterior of microwave and toaster and   - Inside of plate warmer cabinet. * There were 2 holes observed under a prep area table. They were acknowledged by Staff 1 (Executive Director). There was significant ice build up on the door to the walk in freezer, in the walk in freezer as well and noted dripping and rusting areas in the walk in cooler. A large section of exposed pressed wood by a window seal was observed from the smooth cleanable surface pealing off. * Multiple items in walk in cooler found not labeled or dated. * Multiple items in walk in cooler found uncovered. * Multiple employees found not washing hands when entering kitchen area as well as not washing hands when changing from dirty tasks to clean tasks. * Kitchen staff observed to heat up a can of tomato soup and did not check the temperature before serving to resident. * Lunch item temperatures were not checked prior to start of service. They were removed from convection oven, placed in steam table, covers removed and staff served residents. Temperature logs were reviewed and multiple days of food temperatures were not recorded. Staff 1 (Executive director) and Staff 2 (Dining Services Coordinator) acknowledged temperatures were not recorded. * Cleaning task list and schedule was reviewed with Staff 2 and she validated multiple days were missing documentation. She did state that staff frequently forget to write it down. * Plan of correction presented by facility included weekly audits. Staff 1 was asked for documentation that audits were conducted and none was provided. The areas needing cleaning and the failure to follow safe food handling and preparation practices was reviewed on 2/3/23 with Staff 1 (Executive Director) and Staff 3 (Associate Executive Director). They acknowledged the findings.

Facility will implement  Brookdale Menu Manager menus approved by Crandall Corporations Dieticians  as well as real time trainings with kitchen staff. Will follow the Daily Diet Modification sheets. Will provide mid morning, mid afternoon, and evening snacks daily. Utilization of proper portioning serving tools to monitor correct servings of food served Menus will be planned at least 2 weeks in advance and provide residents their copies of the menus. Any substitution will be recorded on the Menu Substitution Log Dining Services Manager, Interim Director, Memory Care Administrator will monitor compliance by doing daily documented audits. Educating our Dining associates by inservices and actual real time trainings in Food safety and sanitation. ALF Main Kitchen Cleaning Schedule is in place. - Floors have been cleaned and is maintained by following cleaning schedules daily. Sweep and mop every after meal or as needed. - Maintenance have scheduled clean up and repairs of vents and fire sprinklers. - Scrubbed, clean and maintaining oven, grill and stovetop area by schedule, done daily by designated associate. - Finished cleaning cooler ceiling and walls. Scheduled cleaning is in place, or clean as needed. - Maintenance contacted repair company to fixed freezer/cooler. - Walls behind juice machine cleaned and being maintained daily. - Open shelving for spices is now organized and being maintained daily - Ordered new can opener to be installed - Microwave in brand new and daily clean up is part of assigned cleaning schedule - Scrubbed and cleaned plate warmer. Daily clean up is part of assigned cleaning schedule - 2 holes have been patched and will be painted - Replaced pressed wood with real wood and will be painted - Dining Leader continues to monitor practice of proper dating and food labeling - inserviced culinary associates. - Spot audits are being done by different department heads to ensure compliance in food safety and sanitation. - Proper heating of RTE food addressed. Instructed servers to request assistance from the cooks to properly take temperatures of any food before serving - Inservices going on for proper food holding temperatures of cold and hot foods. Taking and documenting internal temperatures of food to know if temperatures are correct before placing in steam table. Taking temperatures of food before start of meal service and every 30 mintes thereafter. Hot food should be kept hot, cold foods cold. - Temperature Logs are in place. Dining Leader monitors and inforce daily Continually training and coaching associates to be compliance in Food Safety and Sanitation.

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.

see C 240

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 240 and C 295 .

Please refer to C295

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

Refer to c240

Based on observation and interview, it was determined the facility failed to comply with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to: Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility, except when the employee is alone in a closed room. Observations of staff during the kitchen inspection revealed multiple instances of staff failing to wear their mask properly by covering both their mouth and nose. On 11/22/22, the need to ensure all staff were properly wearing a face mask was discussed with Staff 4 (Executive Director), Staff 5 (Assistant Executive Director), and Staff 6 (Cook). They acknowledged the findings.

Facility will provide written counselling to the staff observed not wearing a mask properly, and written training to all staff regarding mask expectations. Written training will be provided to all memory care staff, and enforced daily The memory care community will be walked daily, and staff on duty observed to ensure masks are being worn properly. Associate Executive Director (Memory Care Administrator)

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

Please refer to C240

Based on interview, observation and review of documentation, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C240

Refer to c240

The findings of the kitchen inspection, conducted 08/11/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services: Meals, and Oregon Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit of the kitchen inspection, conducted on 11/22/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, OARs 411 Division 57 for Memory Care Communities, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 11/22/22, conducted 2/3/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the third revisit to the kitchen inspection of 08/11/22, conducted 04/27/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.